Pulmonology Coding Alert

Question: Our pulmonologist wrote pneumonia in a hospital patients chart without specifying the type. I asked the physician if the patient had Gram-negative bacterial pneumonia, and he said yes. Can I use 482.83?

Alabama Subscriber  
Answer: Use 482.83 (Gram-negative pneumonia NOS) if there is evidence of Gram-negative bacterial pneumonia in the medical record. Without documentation of it through diagnostic test results, 482.83 is inaccurate. There should also be a Gram stain or culture report on the chart to substantiate the bacterial pneumonia.
 
Hospital/facility coding is different from physician coding. Hospitals are paid a specified amount through the DRG (diagnostic-related groups) based on the diagnosis code used. If this situation occurs in the office, the E/M visit (99201-99215) is paid at the same rate regardless of which pneumonia code is chosen, but being specific in documentation will help justify the claim. When you ask a physician to specify the type of pneumonia, make sure he or she answers you in writing.  
 
The Office of Inspector General (OIG) scrutinizes pneumonia coding in facilities, so lack of documentation could raise red flags. The OIGs pneumonia-upcoding project identifies instances when coders assign viral/bacterial pneumonia diagnosis codes when the condition is not present or is not substantiated by the medical record. Originally, the project focused on pneumonia that was coded 482.89 (Pneumonia due to other specified bacteria; other specified bacteria), but it has widened its investigation to include 482.83 as well.