Otolaryngology Coding Alert

Hint: Double-check the documentation before you assign 480-486

You can code your allergist's pneumonia diagnoses with accuracy if you know the disease's organism and pay attention to fifth-digit specificity, coding experts say.

1. Capture the Bug on Paper

Your ICD-9 code should match the physician's final diagnosis - and this diagnosis should specify, when possible, which organism caused the pneumonia. You should be able to find this information on the discharge summary, but if you don't see it, you should ask your physician for more details. "If there's an organism, you want to be sure you've coded it correctly," says Patricia Trela, RHIA, at Deloitte & Touche in Boston.

Tip: Make sure the physician puts the diagnosis in writing because if the government chooses to audit, an oral exchange won't pass muster, Trela says. "If [the diagnosis] isn't documented, in an OIG audit you don't have any ground to stand on."

For example, you receive a chart that simply lists "pneumonia" as the patient's diagnosis. You ask the physician what caused the condition, and he replies, "Gram-negative bacteria."

Before you report 482.83 (Other Gram-negative bacteria), ensure that the medical record includes diagnostic test results that back up that diagnosis, such as Gram stain on a bronchial-washing specimen, a culture of the bronchial specimen, and perhaps additional tests for definitive culture identification.

2. Lab Work Isn't Enough

Even with these test results, remember that you still need the physician's written documentation specifying "Gram-negative pneumonia" to report 482.83. "You can't go by the lab work - [physicians] have got to document it," Trela says. "If you have the lab work, that's the time you should ask the physician, 'Could you tell me what the pneumonia is due to? Do you know the organism?'

"It's always inappropriate for a coder to assign codes based on lab results only," Trela says, referencing the Coding Clinic. "In cases such as this, physicians should be queried to determine the responsible pathogen."

3. Diagnosis Determines Medical Necessity

Your carrier will determine the medical necessity of a visit from the diagnoses. Therefore, the diagnoses should be specific enough to communicate the extent and details of the patient's condition, says Beverly Ramsey, CMA, CPC, CHCC, CHBC, at Doctors Management in Asheville, N.C.
 
Best strategy: "In some practices, I have suggested the office manager take diagnoses off the encounter form entirely and replace it with a space where the providers can write their most relevant codes," Ramsey says.

Then you can create a list of most frequently used diagnoses codes, Ramsey says. You can laminate the list and display it in areas where the physician completes encounter forms. Such a list, Ramsey says, will allow the physician to quickly retrieve the exact diagnoses.

If your practice uses electronic medical records, you can also retrieve what is often called a "short list" of the most relevant diagnosis codes from your electronic medical records program and make it available as a reference tool, Ramsey says.

4. Look Closely Before Reporting 482.89

Strains of pneumonia-causing bacteria resulting from organisms not classified in ICD-9 are rare, so your reporting of 482.83 and 482.89 (Other specified bacteria) should be, too, Trela says. Keep your practice in the clear with these do's and don'ts of pneumonia diagnosis coding: