Pulmonology Coding Alert

Question: A patient developed ventilator associated pneumonia while undergoing treatment for Streptococcus bronchopneumonia. How do we code for this scenario?

Maine Subscriber

Answer: For all procedural or postprocedural complications, you should assign codes based on the provider's documentation of the relationship between the condition and the procedure.

In this case, the ventilator associated pneumonia (VAP) developed after admission. On admission this patient's principal diagnosis was J13 (Pneumonia due to Streptococcus pneumoniae), and he later on developed VAP. As for VAP, you may assign code J95.851 (Ventilator associated pneumonia), as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.

Remember: Do not assign code J95.851 for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.