Pulmonology Coding Alert

High on the federal governments hit list is pneumonia upcoding. As part of its workplan for fiscal year 2000, the Office of the Inspector General (OIG) of the U. S. Department of Health and Human Services (HHS) specifically mentioned pneumonia upcoding in the list of things for which it will be watching. Hospitals that insist physicians keep complete patient records with full documentation of medical decisions need not worry about passing OIG audits.

The pneumonia-upcoding project focuses on identifying hospitals where coders are assigning viral/bacterial pneumonia diagnosis codes when the condition is not present or is not substantiated by the medical record documentation. Originally, the project was concerned primarily with pneumonia that was coded 482.89 (pneumonia due to other specified bacteria; other specified bacteria) but has since widened its investigation to include 482.83 (pneumonia due to other specified bacteria; other gram-negative bacteria). Another issue added to the list is when a hospital coder uses 482.89 instead of 482.9 (bacterial pneumonia unspecified), according to William Haik, MD, a pulmonologist in Ft. Walton Beach, Fla., and director of DRG Review, a hospital coding consulting firm. Actually, there are codes for most types of pneumonia. Any particular strain of pneumonia-causing bacteria that is not classified in the ICD would be very rare indeed. The difference may be subtle, but the red flags potentially raised during an audit are not, says Haik.

The more serious strain of pneumonia (482.89 and 482.83) falls under the diagnosis related group (DRG) 079. The cases that rightly should fall under DRG 089 keep the pneumonia DRG-upcoding project on the front burners at HHS and the U.S. Department of Justice (DOJ).
According to the HHS OIG semiannual report released in March, The OIG has found that a small percentage of hospitals across the country have assigned a disproportional number of pneumonia cases ICD-9 codes that result in a diagnosis being assigned the higher-paying DRG. According to a spokesperson for HHS OIG, to date 17 hospitals have settled their liability for such coding by paying more than $21 million and agreeing to initiate integrity requirements. Earlier this year, three hospitals were forced to pay a total of nearly $5 million as a result of their pneumonia upcoding.

OIG specifically targeted pneumonia upcoding for the past few years, and for 2000 has upgraded its Pneumonia DRG Upcoding Project to priority status.
Haiks advice to coders is to query the attending physician to make sure that the organism is linked to the condition, and scrutinize the manual carefully to ensure that, before using 482.89, the identified organism is definitely not included in the classification list.

It is not enough simply to document pneumonia in the medical record. At [...]