Radiology Coding Alert

Check where the embolus is located and where it originated.

To successfully report embolisms, the embolism origin is the main deciding factor in choosing the primary diagnosis. However, code selection isn’t foolproof. Check out four possible places where you can slip and end up at the wrong end of claim rejections.

Pitfall 1: Septicemia isn’t Your Primary Diagnosis

You may be successfully identifying the exact embolism code, but if you report the embolism code as your primary code, you are fishing for trouble. Whatever the type of embolism you encounter, the golden rule is this: You always code the underlying cause of the embolism first and then the type of embolism.

Case: A 45-year-old patient with a history of heavy smoking presents with fever, shortness of breath, and pulmonary infiltrates, one of which has a small cavity in it. Blood culture reveals bacterium staphylococcus aureus, and your physician reports tricuspid endocarditis in his medical record. You should code 038.11 (Methicillin susceptible staphylococcus aureus septicemia) for the staphylococcal septicemia, 421.0 (Acute and subacute bacterial endocarditis) for acute bacterial endocarditis, which entails that you add code 041.11 (Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site) for identifying the infectious organism of the bacterial endocarditis, and 415.12 (Septic pulmonary embolism) for septic pulmonary embolism.

The case demonstrates that along with 415.12, you have to also report another code identifying the septicemia (038.0-038.9).

ICD-10 options: The code 415.12 for septic pulmonary embolism corresponds to codes I26.90 (Septic pulmonary embolism without acute cor pulmonale) and I26.01 (Septic pulmonary embolism with acute cor pulmonale) in ICD-10. You choose amongst these 2 codes depending upon whether your physician documents cor pulmonale (changes in the heart) along with septic pulmonary embolism.

Note: 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 513.0 (Abscess of lung).

ICD-10 offers multiple options: ICD-10 will offer you a choice of three codes for reporting lung abscess. You need to check for a concomitant pneumonia with lung abscess. When your physician documents a lung abscess with pneumonia, you submit ICD-10 code J85.1 (Abscess of lung with pneumonia). If your physician documents no pneumonia with the lung abscess, you report J85.2 (Abscess of lung without pneumonia). When your physician documents that the lung was totally necrosed or gangrenous, you turn to code J85.0 (Gangrene and necrosis of lung).

Pitfall 2: You Mistake ‘Arterial’ Embolism for ‘Pulmonary’

If you find it difficult to differentiate between the two main types of septic embolism, look at the medical record to find the embolus’s origin and the final location. 

Arterial: A septic arterial embolus may originate from a central infection, such as in the heart (for instance, infective endocarditis, primarily left-sided). The embolic material travels through the systemic arterial system to lodge in small vessels anywhere in the body, such as the brain, the retina, or the digits.

Pulmonary: On the other hand, a septic pulmonary embolus will originate 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.

You will never go wrong if you have captured two facts correctly from the physician’s medical records –whether the emboli has been described as “septic” and the embolism’s “location.” If you can’t confirm both these facts from the physician’s clinical documentation, then you should go through additional reports or diagnostic studies (such as blood cultures, chest computed tomography, chest X-ray, or transesophageal echocardiography) that demonstrate and confirm the presence of multiple, nodular lung infiltrates in the periphery of the lung, with or without cavitation.

Real life scenario: A patient would often have an indwelling catheter or device and would typically present with insidious onset of fever and respiratory symptoms. In this scenario, make sure you gently persuade the physician to document the diagnosis to the highest specificity of the patient’s condition. This will save you later headaches while billing for the hospital’s claims as well as the physician’s professional services.

Pitfall 3: You Ignore 449 for Septic Arterial Embolism

Once you have correctly established that the diagnosis is of a septic embolism of the “artery,” you can safely code the condition specifically with 449 (Septic arterial embolism), which describes a septic embolism of any artery.

Watch for the one-to-one match in ICD-10: The corresponding ICD-10 code for septic arterial embolism is I76 (Septic arterial embolism).

You have to remember that you’ll never use 449 as the primary code. When your physician diagnoses a patient with septic arterial embolism, you will first code the underlying infection, such as infective endocarditis (421.0) or lung abscess (513.0).

Case: A patient with bacterial endocarditis develops a cold lower extremity due to an arterial thrombosis originating from the heart. You would code 421.0, 449, and 444.22 (Arterial embolism and thrombosis of lower extremity) for the specific site of the embolism.

Pitfall 4: You Aren’t Using the Septic Pulmonary Embolism Code

You may be missing out on deserved reimbursement if you are not using the fifth digit “2” enough in the subcategory 415.1x (Pulmonary embolism and infarction) of ICD-9 list enough. That’s right; you may be still be using an “other specified” code for septic embolism instead of the specific code 415.12.

Just make sure that you have pinpointed the primary condition first and also confirmed that there is no chronic pulmonary embolism (416.2, Chronic pulmonary embolism) mentioned in the physician’s medical record. This corresponding direct match in ICD-10 is I27.82 (Chronic pulmonary embolism).

Finally, if you still end up with your physician’s note that mentions non-identification of the septic embolism type, you can always revert safely to 415.12 for septic embolism not otherwise specified (NOS).