Pulmonology Coding Alert

Still feeling your way into the new septic embolism ICD-9 subcategory? You know you should relegate the new code to at least the secondary diagnosis and choose a primary diagnosis based on the disease's origin, but what else should you keep in mind? We'll point you to five signs that indicate your coding is on the right track.

In 2008, ICD-9 added a new code in its 415.1x (Pulmonary embolism and infarction) subcategory list: 415.12 (Septic pulmonary embolism).

Best bet: You'll be able to specify this disease, rather than having to lump it under  an "other specified" code. Previous editions of ICD-9 before 2008 contained no entry for embolism, septic. "Septic pulmonary embolism currently would be coded to 415.19 (... other), along with codes for septicemia and sepsis, as appropriate," according to the ICD-9-CM Coordination and Maintenance Committee Meeting minutes of Sept. 28-29, 2006.

Example: A hospital admits a 67-year-old chain smoker with fever, shortness of breath, and pulmonary infiltrates, one of which has a small cavity in it. Staphylococcus aureus is cultured from the blood, and the pulmonologist diagnoses tricuspid endocarditis. "You would code 038.11 for the staphylococcal septicemia, 421.0 for acute bacterial endocarditis, which suggests you also report 041.11 for staphylococcus aureus (for the infectious organism of the bacterial endocarditis), and 415.12 for septic pulmonary emboli," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

The example tells you that along with 415.12, you would also bill for another code identifying the septicemia (038.0-038.9).

Caution: If septic pulmonary embolism (SPE) also causes a subsequent lung abscess or necrotizing pneumonia, you should code that condition as well. Report either the lung abscess or necrotizing pneumonia as 513.0 (Abscess of lung).

Sign 3: You Utilize 449 for Any Septic Arterial Embolism

Another code which debuted in ICD-9 2008 was for another septic disease diagnosis: 449 (Septic arterial embolism), which describes a septic embolism of any artery. Now you'll classify the disease under the 449 category.

Just like 415.12, you'll never use 449 in the primary position. When a pulmonologist diagnoses a patient with septic arterial embolism, you will first code the underlying infection, such as infective endocarditis (421.0, Acute and subacute bacterial endocarditis) or lung abscess 513.0 (Abscess of lung).

Example: A patient with bacterial endocarditis develops a cold lower extremity due to an arterial thrombosis originating from the heart. You would code 421.0 (Acute and subacute bacterial endocarditis), 449 (Septic arterial embolism), and 444.22 (Arterial embolism or thrombosis, lower extremity) for the specific site of the embolism.

If you can't distinguish between the two main types of septic embolism, look to where the embolus starts and ends up. According to the ICD-9 diagnosis agenda, "A septic arterial embolus may originate from a central infection, such as in the heart" (for instance, infective endocarditis, primarily left-sided). The embolic material travels through the systemic arterial system to lodge in small vessels anywhere in the body, such as the brain, the retina, or the digits."

In contrast, a septic pulmonary embolus can originate from a localized infection such as a localized cellulitis or a central venous catheter infection. The embolic material travels through the venous system to the right side of the heart and goes into the pulmonary arterial system where it lodges in small vessels.

There are two key phrases that should ring a bell when you review the pulmonologist's documentation:

1. the embolism's location

2. a description of the embolus as "septic."

If the note lacks either piece of information, you may "review additional reports or diagnostic studies (such as blood cultures, chest computed tomography, chest X-ray, or transesophageal echocardiography) that document and confirm the presence of multiple, nodular lung infiltrates in the periphery of the lung, with or without cavitation," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

Picture this: A patient would often have an indwelling catheter or device and would typically present with insidious onset of fever and respiratory symptoms. In this scenario, make sure you educate the physician regarding documentation to the highest specificity of the patient's condition. "This will support not only the claims for the physician's professional services but also the hospital's claims," Pohlig says.

If the pulmonologist can't identify the septic embolism type, you have an easy way out. Septic embolism not otherwise specified (NOS) will be classified to 415.12. Pulmonary is the most common site, explained NCHS staff in the ICD-9-CM Coordination and Maintenance Committee Meeting Sept. 29, 2006, Summary.