Primary Care Coding Alert

Question: A patient of ours was hospitalized for pneumonia. On release, the patient received treatment from one of our providers. The patient is still on medication for the condition, and the doctor ordered X-rays, which showed the pneumonia is still active. As the patient has been discharged from the hospital, I am being told to use a history code to describe the condition, yet the medication and X-ray order tell me that the condition is still active. How should I code this?

Ohio Subscriber

Answer: When a patient is discharged from the hospital, the discharge does not mean that the condition has resolved. A patient is discharged when the hospital determines that it is safe for the patient to no longer receive hospital care. Very often in such cases, the patient continues to need care, but the hospital has decided that the patient can now receive that care on an outpatient basis.

This seems to be the case according to your description. Consequently, you would not use a history code such as Z87.01 (Personal history of pneumonia (recurrent)), and there are no guidelines that would point you toward coding the patient’s condition in this way. Instead, a code such as J18.9 (Pneumonia, unspecified organism) would be far more appropriate to use in this encounter where, as you note, the pneumonia seems to be an active problem as demonstrated by the X-ray and treatment through medication.

But, as always, code choice will be dependent on your provider’s documentation; so never assume that what you’ve heard is how a code should be assigned.