Pulmonology Coding Alert

See why you should wait for physician's final diagnosis before settling for a code.

Pneumonias are differentiated by clinical findings and findings on physical examination, and coding the specific condition could be risky. If a claim confirms pneumonia for a patient who presented with symptoms, would you know what to do with the results? Consider this scenario:

A patient sees a pulmonologist who orders a chest x-ray because of a persistent cough. The result of the chest x-ray indicates the patient has pneumonia. A pulmonologist performs a sputum culture, and confirms the Eaton's agent pneumonia -- a type of pneumonia caused by the organism mycoplasma pneumoniae. The interpreting physician should report a primary diagnosis of pneumonia.

Easy? Not so fast. The ICD-9 lists several classifications of pneumonia that covers 480-486 of the manual. Overuse of the diagnosis codes for specified bacteria has, in fact, been rampant among coders of pulmonology. Don't be part of the statistics. Debunking these 2 myths could safeguard you from a potential denial.

1. One Pneumonia Code Fits All

The key to a successful claim for pneumonia is in your physician's final diagnosis. This diagnosis should specify what organism caused the pneumonia. If you have a hard time deciding on the final diagnosis, you can always ask your physician for more details.

Remember: If your physician's notes simply say "pneumonia," it's not enough. You should ask the physician if there is a confirmed cause of the condition. For instance, the diagnostic test results in the above scenario are pretty clear on what organism caused the pneumonia: Mycoplasma pneumonia. Therefore, you should bill the condition with 483.0 (Pneumonia due to mycoplasma pneumoniae).

Diagnostic workup typically includes chest x-rays, and blood and sputum cultures. If the physician does not identify a causal organism, such as staphylococcus or streptococcus, you would assign code 486 (Pneumonia, organism unspecified).

Caution: 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 still works best.

The American Hospital Association's Coding Clinic, in its Second Quarter 1998 release, provides the following guidelines for coding pneumonia:

• Never assume
• Do not assign codes based on lab or x-ray.

"It is inappropriate for coders to assume a causal organism on the basis of laboratory or radiology findings alone," according to the paper.

2. Patient's Symptoms Tell You Nothing

Patients with bacterial pneumonias often present symptoms such as chronic cough (786.2, Cough), fever with chills (780.60, Fever, unspecified), and chest-wall pain (786.52, Painful respiration). You cannot identify bacterial pneumonia based solely on sputum culture or assigning code 482.89 (Pneumonia due to other specified bacteria).

If the physician documents bacterial pneumonia without further specification, you should talk to her for clarification. If you can't find further documentation, you should bill the diagnosis with 482.9 (Bacterial pneumonia, unspecified).

Example: An 80-year-old patient presents to the office with fever, shortness of breath and productive cough. Chest x-ray shows infiltrate involving the left lower lobe. The physician documents mixed bacterial pneumonia on discharge. On your claim, you should assign 482.9. If the physician had documented two or more specified organisms, you should code all types of pneumonia.

Alternative: Sometimes the symptoms would be similar to influenza and include fever, a dry cough, headache, muscle pain and weakness. These symptoms would then progress to breathlessness, productive cough and fever. If you see these signs on the pulmonologist's chart, you should pick out a code for viral pneumonia to report the diagnosis in the category 480. For instance, 480.3 (Pneumonia due to SARS-associated coronavirus) is a valid viral pneumonia code.