Pulmonology Coding Alert

Advise: Consider alternate diagnoses until the patient's condition is accurate.

Coding ventilator-associated pneumonia (VAP) offers more grey area that what you'd expect. In fact, not all cases of ventilated patient with pneumonia call for 997.31. Avoid a potential audit by making the need for the diagnosis less frequent. Here are some key points to look into for VAP-coding guidance.

Overzealousness Spoils 997.31 Diagnosis

While many physicians treating pneumonia for a patient on a ventilator would simply code the diagnosis as VAP (997.31), this practice is simply off the mark. Often, pulmonologists do not order a chest xray or a culture when trying to diagnose VAP. This makes getting an accurate diagnosis more difficult. Don't be too quick to report 997.31 only because the patient is ventilated, and is showing signs of pneumonia.

First, you should consider the patient's history and possible alternate diagnoses, such as heart failure (428.9), hemoptysis (786.3), acute respiratory distress syndrome (ARDS, 518.82), and influenza (487.x) -- all of which can appear like VAP.

Quick fact: VAP is a "diagnosis of exclusion," belonging to the category of hospital-acquired diseases. You should attempt to rule out VAP with a trachea culture combined with a new or enlarging infiltrate chest xray, or a bronchoscopy plus bronchoalveolar lavage with a new or enlarging infiltrate chest xray, says Jill M. Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich.

Organism Makes Up Other Half Of VAP Coding Routine

ICD-9 guidelines direct the usage of an additional code to identify the organism causing the infection. Most of these infections are due to gram negative organisms, such as Pseudomonas, or staph (methicillin-susceptible staph aureus [MSSA] or methicillin-resistant staph aureus [MRSA]), explains Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta.

For instance, when billing ventilator-associated pneumonia, you might report:

• 997.31 and 482.1 (Pneumonia due to Pseudomonas)
• 997.31 and 482.41 (Methicillin susceptible pneumonia due to Staphylococcus aureus), or
• 997.31 and 482.42 (Methicillin resistant pneumonia due to Staphylococcus aureus).

Example: A physician diagnosed a patient with ventilator-associated pneumonia (VAP) caused by pseudomonas aeruginosa. The physician monitored the ventilator, and the patient did not require critical care.

You would report the E/M using ventilator management codes (94002-94004). For the ICD-9 codes, you should link 997.31 and 041.7 (Pseudomonas infection in conditions classified elsewhere and of unspecified site) to the CPT®. Consistent with the ICD-9 guidelines, you should assign an additional code to identify the causative organism but only if confirmed -- in this case, 041.7.