Pulmonology Coding Alert

Question: The pulmonologist was treating an inpatient for apparent pneumonia. The culture results determined that it was Gram-negative bacterial pneumonia. When reporting the subsequent hospital service he provided (99231-99233), the physician assigned Gram-negative bacteria-specific pneumonia as the diagnosis.

He gave me this diagnosis verbally, but I can't find the diagnosis anywhere in the documentation. Should I report the patient's pneumonia as Gram-negative bacteria-specific pneumonia?


Massachusetts Subscriber


Answer: If you have the proper documentation  to support it (such as, a pathology or lab report identifying the cultured bacteria as Gram-negative), you should report Gram-negative bacteria (482.83, Other Gram-negative bacteria) as the cause for the patient's pneumonia.

A good rule to always follow is that you want to make sure that the ICD-9 code you choose matches your pulmonologist's final diagnosis, and this diagnosis should specify, when possible, which organism caused the patient's pneumonia.

Tip: Make sure the pulmonologist puts the diagnosis in writing because if the insurer chooses to audit your practice, an oral exchange won't pass muster.

As described above, the pulmonologist's documentation may only specify "pneumonia" as the patient's diagnosis. If this is the case, you may ask the pulmonologist what caused the condition or review the pathology reports yourself.

But even if your pulmonologist states that Gram-negative bacteria caused the patient's problem, before you report diagnosis code 482.83 you should make sure that the documentation includes "Gram-negative bacteria" as the cause.

Remember: The medical record must include diagnostic test results that back up that diagnosis, such as Gram stain on a bronchial-washing specimen, a culture of the bronchial specimen, and perhaps additional tests for definitive culture identification.