Pulmonology Coding Alert

The presence or absence of this added complication virtually decides your diagnosis.

Facing the task of reporting pulmonary embolism can be confusing if you don’t arm yourself with the right information. You know you should distinguish between an old and acute clot, use the code as the secondary diagnosis and choose a primary diagnosis based on the disease’s origin, but what else should you keep in mind? Find out.

Rule 1: Knowledge Wins Half the Embolism Coding Battle

Pulmonary embolism is a blood clot in the lung that usually comes from smaller vessels in the leg, pelvis, arms, or heart. The clot travels upward through the vessels of the lung continuing to reach smaller vessels until it gets trapped in a vessel that is too small to allow it to continue farther. The block prevents any further blood from traveling to that section of the lung.

To diagnose or rule out this condition, the pulmonologist would usually order a ventilation/ perfusion study. When reporting pulmonary embolism, you would code from the family I26.-- (Pulmonary embolism). The code covers pulmonary (acute) (artery)(vein) infarction, pulmonary (acute) (artery)(vein) thromboembolism, and pulmonary (acute) (artery)(vein) thrombosis.

However, before coding the condition, you will have to familiarize yourself with a new term:

• Cor pulmonale: abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.

The presence or absence of this added complication virtually decides the direction your coding goes in deciding the final code. If the pulmonologist notes cor pulmonale during the encounter, you will select from I26.0- (Pulmonary embolism with acute cor pulmonale) and I26.9- (Pulmonary embolism without acute cor pulmonale). For example, a case of simple septic pulmonary embolism will map to I26.90 (Septic pulmonary embolism without acute cor pulmonale). If the physician can confirm the underlying infection, you would report this code as well.

Coder tip: If the pulmonologist can’t identify the type of pulmonary embolism, you have an easy way out. “Pulmonary embolism not otherwise specified (NOS) will be classified to I26.99,” informs Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.

Rule 2: Separate the Acute Conditions From the Chronic

Use the I26 family only to explain a new, acute pulmonary embolism. However, you should not use these codes where the physician notes old or chronic embolisms. For chronic unresolved embolisms, you should turn to I27.82 (Chronic pulmonary embolism).

You will use this code when a patient with unexplained dyspnea (R06.0-, Dyspnea) or with a pulmonary hypertension (I27.2, Other secondary pulmonary hypertension) displays evidence of pulmonary embolism on a CT scan or pulmonary angiogram, without evidence of a recent event.

Example 1: A pulmonologist works up a patient with secondary pulmonary hypertension (I27.2) and determines that an existing clot, remains undissolved in one of the pulmonary arteries. You would report a chronic pulmonary embolism (I27.82).

Example 2: A patient presents with signs and symptoms of chronic obstructive pulmonary disease (J44.1, Chronic obstructive pulmonary disease with [acute] exacerbation). Upon evaluation, the patient remains with a small subsegmental pulmonary embolism but is no longer on active therapy. In this case, you should again code I27.82 for the diagnosis.

Advantage: When you know the difference between a chronic thrombus and an acute one, you’d be able to document the need for continuing an established therapy versus initiation or intensification of anticoagulant therapy.

Don’t confuse: Use the Z code Z86.711 (Personal history of pulmonary embolism) when there is only a history of a pulmonary embolism, and it is no longer present and not relevant to the reason for a current evaluation. Similarly, for pulmonary embolism due to complications of surgical and medical care, you will use codes from T80.0 (Air embolism following infusion, transfusion and therapeutic injection), T81.7- (Vascular complications following a procedure, not elsewhere classified), or T82.8- (Other specified complications of cardiac and vascular prosthetic devices, implants and grafts) families.

Rule 3: Sequence Embolism Codes Second

Although, you may know all the embolism codes, your arsenal may be incomplete because, when reporting embolism, you will code first the underlying infection, such as septicemia (A40.9-A41.9) if it is known. Septic pulmonary embolism is an uncommon disorder that generally presents with an insidious onset of fever (R50.9, Fever unspecified), cough (R05), and hemoptysis (R04.2, Hemoptysis; R04.9; Hemorrhage from respiratory passages, unspecified).

“These are not manifestation codes that require a primary diagnosis. They are codes that suggest using a primary diagnosis code, when it is possible, but would be accepted for professional billing as a primary diagnosis. It cannot be used as a “principal dx” for DRG reporting,” Pohlig adds.

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 A41.01 (Sepsis due to Methicillin susceptible Staphylococcus aureus) for the staphylococcal septicemia, I33.0 (Acute and subacute infective endocarditis) for acute bacterial endocarditis, and I26.90 for septic pulmonary emboli. The example tells you that before I26.90, you should also bill for another code identifying the septicaemia

(A41.0-A41.9, Other sepsis). You should also report B95.61 (Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere) for the infectious organism of the bacterial endocarditis.

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 J85.2 (Abscess of lung with pneumonia) or J85.0 (Gangrene and necrosis of lung).

Rule 4: Pick Precisely Between Pulmonary and Arterial Embolisms

Other than pulmonary embolism code I26.--, you should keep track of another septic diagnosis: I76.-- (Septic arterial embolism), which describes a septic embolism of any artery. If the pulmonologist cannot identify the septic embolism at all (pulmonary or arterial), then also you will code the embolism as I76.

For making the correct choice between these two main septic embolism codes, you should understand the difference between ‘arterial’ and ‘pulmonary.’ To distinguish between the two main types of septic embolism, look to where the embolus starts and ends up. A septic arterial embolus may originate from a central infection, such as in the heart and then travel through the systemic arterial system to lodge in small vessels anywhere in the body, such as the brain, the retina, or the digits.

However, a septic pulmonary embolus originates 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.

Two key phrases that should ring a bell when you review the pulmonologist’s documentation are:

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.

Tip: Just like I26, you’ll sequence code I76 as the secondary diagnosis. When a pulmonologist diagnoses a patient with septic arterial embolism, you will first code the underlying infection, such as infective endocarditis or lung abscess.