Pediatric Coding Alert

Question: Which ICD-9 code should we use for pneumonitis? I had been using "486" but one of our physicians disagreed with this? Please tell me if I am reporting the diagnosis incorrectly.

New York Subscriber

Answer: The key to a successful claim for pneumonia is in the final diagnosis. This diagnosis should specify what organism caused the pneumonia, but it's the exception rather than the rule that a pediatrician would know the organism at the time of the initial diagnosis. Diagnostic workup typically includes chest x-rays, blood and sputum cultures. If the physician does not identify a causative organism, such as staphylococcus or streptococcus, you would assign code 486 (Pneumonia, organism unspecified).

If the medical notes simply say "pneumonia," it may not be enough. You should ask the physician if there is a confirmed cause of the condition. However, identifying the specific causative organism is usually not possible at the initial E/M visit. You should be careful when coding 486 when there is clinical evidence of a more specific type of pneumonia being treated. Although this is a very common pneumonia code, querying the physician to clarify unclear, ambiguous, or inconclusive documentation may be necessary.

The ICD-9 manual lists several classifications of pneumonia that covers 480-486 of the manual. If no specific organism is identified to be the cause of the pneumonia, as is often the case, you can settle for 486. If the causative organism is identified then you will have to report the specific code for that causative organism. For instance, pneumonitis caused due to streptococcus pneumoniae is reported using 481 (Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]). 507.0-507.8 describes pneumonitis caused by inhalation of solids or liquids.