Pulmonology Coding Alert

Pinpoint the causative organism to wade through fifty plus choices.

Does choosing the correct code for pneumonia give you chills? Don’t blame yourself, choosing from a list of fifty plus codes is a daunting task. Pneumonia can occur due to a variety of causes, and you will need to develop a keen eye for the specific cause documented by the provider so as to pick on the right code.

What is the most common difficulty that coders come across while reporting a right code for pneumonia? “The difficulty arises in finding the documentation that accurately identifies the cause of the pneumonia,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

“It is important that the physician document in the medical record the exact type of pneumonia so a coder does not need to guess,” says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society. “Coders need to encourage their physicians to be specific in the documentation of’ the type of bacteria that caused the pneumonia.”

Basics: The clinical features of pneumonia include tachypnea, fever, dyspnea and hypoxia. Respiratory infections that can cause pneumonia range in complexity and specific causes. Some of the causes one may typically come across could be bacterial, viral, aspiration, iatrogenic cause, and pneumonia due to other organisms such as fungal, parasitic, mycosis etc.

“During the investigative phase of testing, the cause may not be identified,” Pohlig says. “If confirmed through diagnostic testing, the coder should select the confirmed causative agent as the diagnosis.”

Look Out For the Bacterial Pneumonias

You have numerous codes for bacterial cause of pneumonias, mostly from the code category J15.

In order for you to decide the correct code from 13 possible code options, you will need to know the exact causative organism, such as Klebsiella, Pseudomonas, staphylococcus, staphylococcus, streptococci and Escherichia coli.

Example: The provider diagnoses a patient with pneumonia along with an abscess in the right lung. The reports show the causative organism as Klebsiella pneumoniae. How do you code for this situation?

Pneumonia due to Klebsiella is a diagnosis that might seem fairly easy to code, but don’t get ahead of yourself. Yes, you do have a dedicated code for this case (J15.0, Pneumonia due to Klebsiella pneumoniae), but you will need to be careful as you need to code the associated abscess first: J85.1 (Abscess of lung with pneumonia).

That’s not all. Before picking a bacterial pneumonia code in haste, you need to remember that according to CMS if the patient happens to have associated viral influenza as well, you should not miss reporting that with J09.X1 (Influenza due to identified novel influenza A virus with pneumonia), J10.00 (… other identified influenza virus with unspecified type of pneumonia), or J11.00 (… unidentified influenza virus with unspecified type of pneumonia).

Explore the Possibilities in Viral Pneumonia

You will also need to be aware of code options for pneumonia due to viral causes. While Category J12 talks of viral pneumonias such as SARS and syncytial virus; category J10 and J11 have codes for an influenza with associated pneumonia.

Example: Let’s tackle another case. A patient has influenza with pneumonia, and the provider documents the presence of novel influenza A virus and parainfluenza virus. How do we code this?

You do have a specific code J12.2 (Parainfluenza virus pneumonia). However, we will need to first report the influenza A virus. So, the first code would be J09.X1 (Influenza due to identified novel influenza A virus with pneumonia).

Check for Pneumonia Due To Other Causes

If you identify that the cause of pneumonia is not bacterial or viral, you may go on to find out causes such as fungal, parasitic, mycosis, aspiration. You have about 20 coding options to consider. The causative organism could be rubella, Salmonella, spirochete, actinomycetes amongst many others.

“With so many types of pneumonia it is important for the coder to learn where to obtain the specific information in the medical record,” Berman says. “Also make sure the physician correctly documents the specific cause of a pneumonia so it can be coded correctly.”

Check Out the Possibilities of Aspiration

Aspiration is one important cause of pneumonia. Yes, you do have a dedicated category J69.- (Pneumonitis due to solids and liquids), but you will need to be careful in picking the exact code here as well.

Example: The provider comes across a case of inhalation of regurgitated food. The provider finds the presence food particle in the trachea, and patient has aspiration pneumonia. Here you might use J69.0 (Pneumonitis due to inhalation of food and vomit) as it covers aspiration pneumonia due to food regurgitation, gastric secretions, milk and vomiting, but it also requires you to code for an associated foreign body in respiratory tract (T17.-).

Watch Out for Iatrogenic Pneumonia

Pneumonia may ensue as a complication or result of a medical procedure as well. If the documentation suggests that the patient developed pneumonia during his treatment while on a ventilator, you may assign the code J95.851 (Ventilator associated pneumonia). You will need to use additional code to identify the organism, if known (B95.-, B96.-, B97.-). However, this code codes not cover the ventilator lung in newborn (P27.8).

At times, there may be an additional diagnosis such as sepsis (R65.2-) or respiratory failure (J96.-), for which you would need additional documentation.

Final takeaway: “Selecting the correct code for pneumonia depends upon proper physician documentation,” Pohlig says. “Ensure that the physician understands the importance of documenting and updating the information about the cause of pneumonia throughout the stay.”