Pediatric Coding Alert

Starting this October, you’ll be required to report J18.9 for pneumonia.

Although your pediatric practice has grown accustomed to reporting a code from the 486 series for patients with pneumonia, that will change dramatically in October, when you’re required to start billing under the ICD-10 system.

ICD-9 Coding Rules: Currently, the ICD-9-CM code set provides one diagnosis code for pneumonia caused by an unspecified organism: 486 (Pneumonia organism unspecified). Coding guidelines specify that diagnosis 486 excludes hypostatic or passive pneumonia, inhalation or aspiration pneumonia due to foreign materials, or pneumonitis due to fumes and vapors.

If your provider does not document a specific organism that caused the patient’s pneumonia, you submit diagnosis 486.

ICD-10-CM Code: Starting in October, however, you’ll look to J18.9 (Pneumonia, unspecified organism) for this condition.

You’ll find the diagnosis in ICD-10 under Chapter 10, Diseases of the Respiratory System, the Influenza and Pneumonia block.

Documentation: Pneumonia may be suspected when the pediatrician examines the patient and hears coarse breathing or crackling sounds when listening to a portion of the chest with a stethoscope. There may be wheezing, or the sounds of breathing may be faint in a particular area of the chest. A chest X-ray may be ordered to confirm the diagnosis of pneumonia.

Additional tests to confirm a pneumonia diagnosis could include blood tests or taking sputum samples. The physician’s documentation of these tests must support any additional codes you report.

Coder Tips: ICD-10 guidelines provide numerous tips for coding pneumonia and other respiratory conditions. For example:

• List any type of associated influenza first on your claim, if applicable (J09.01-, J09.11-, J10.0-, -J11.0-)
• Use additional codes (when applicable) to identify exposure to tobacco smoke, history of tobacco use, or tobacco dependence.

Several codes in the J18 code block describe other types of pneumonia due to unspecified organism (bronchopneumonia, lobar pneumonia, hypostatic pneumonia). Verify that none of these diagnoses is a better reflection of the documentation before you submit J18.9.

If your pediatrician orders lab tests to confirm the diagnosis, your documentation must include a copy of the lab report.