Pneumonia is a common infection or inflammation of the lung that can be caused by bacteria, viruses, parasites and other organisms. Pneumonia is one of the leading causes of death in the U.S. and is a concern particularly for the elderly. However, throughout the world it is one of the leading causes of death in children.
Pneumonia coding remains a top the Office of the Inspector General (OIG) initiative. The central focus of the OIG relates to the over utilization of the diagnosis codes for specified bacteria. Therefore coding pneumonia correctly is essential.
The following ICD-9-CM codes and categories from Chapter 8, Diseases of the Respiratory System, are commonly used to code pneumonia:
480.X, Viral Pneumonia
481, Pneumococcal Pneumonia
482.X, Other bacterial pneumonia
483.X, Pneumonia, due to other specified organism
485, Bronchopneumonia, organism unspecified
486, Pneumonia, unspecified organism
507.X, Pneumonitis due to solids and liquids (inhalation)
There are pneumonia codes from Chapter 1, Infectious and Paracitic Diseases, that are also used and they include:
003.22, Salmonella pneumonia
055.1, Postmeasles pneumonia
011.6, Tuberculous pneumonia
052.1, Varicella (hemorrhagic) pneumonia
Pneumonia may also be coded as a manifestation of an underlying infection classified in Chapter 1. In these instances two codes are required. The code identifying the underlying infection is coded first followed by a code from category 484, Pneumonia in infectious diseases classified elsewhere. Examples of these conditions include:
Pneumonia in whooping cough-033.9 and 484.3
Bronchial pneumonia in typhoid fever- 002.0 and 484.8
Pneumonias are differentiated by clinical findings and findings on physical examination. Symptoms of pneumonia vary but often include fever, chills, lethargy, cough, chest pain, shortness of breath, headache and weakness. Pneumonia often follows a cold or influenza, but can also be associated with other illnesses.
Diagnostic workup typically includes chest X-rays, and blood and sputum cultures. In up to 65 percent of cases, the organism that is causing pneumonia is not identified. When the organism causing the pneumonia is not documented in the medical record and the physician only states the patient has pneumonia, code 486 is assigned. When the organism causing the pneumonia is known, the code identifying specific organism is assigned; for example, 482.41, pneumonia due to Staphylococcus aureus, and 482.2, pneumonia due to H. influenza.
Bacterial pneumonias often have a sudden onset with productive cough, fever, chills and chest-wall pain. Identifying bacterial pneumonia based solely on sputum culture or assigning ICD-9-CM diagnosis code 482.89, Pneumonia due to other specified bacteria, when the physician states simply bacterial pneumonia, is inappropriate. If the physician documents bacterial pneumonia without further specification, they should be queried for appropriate code assignment. If further documentation is not present, the diagnosis should be coded to 482.9, Bacterial pneumonia, unspecified.
In viral pneumonia, the symptoms are similar to influenza and include fever, a dry cough, headache, muscle pain and weakness. Symptoms then progress to breathlessness, productive cough and fever. Viral pneumonia is coded to category 480. An example of viral pneumonia is code 480.3, Pneumonia due to SARS-associated coronavirus.
Lobar pneumonia is a synonym for pneumococcal pneumonia and is coded to 481. Lobar pneumonia and pneumonia that refers to the affected lobe are not the same unless documented by the physician. For example, pneumonia of left lower lobe is coded to 486.
Aspiration pneumonia results from the inhalation of food, liquids, oils, vomit or microorganisms. When assigning aspiration pneumonia codes from category 507, it is important to review the medical record for documentation that the patient has aspirated food or another substance causing the pneumonia. Documentation should indicate the substance aspirated as well as the risk factors for aspiration. For example, bedridden, sedentary, difficulty swallowing, etc. It is possible for a patient to develop pneumonia from both aspiration and other organisms. In this instance codes from categories 507 and 480-483 should be assigned.
The physician must document a final diagnosis of pneumonia in the medical record. It is not appropriate to add specificity to a physician's unqualified diagnosis of pneumonia based upon a sputum culture, blood culture or lung biopsy unless confirmed and documented by the physician. Unfortunately sputum cultures are of limited value in identifying the specific organism, particularly when antibiotics have been previously administered. Many sputum cultures are contaminated and can be misinterpreted as culture growths of an infectious organism in the lungs. If the documentation is unclear, regarding the type of pneumonia, the physician should be queried. See Coding Clinic, Third Quarter 1994, page 10 and Third Quarter 1994, page 18 for a discussion of this point.
Coding Clinic, Second Quarter 1998, pages 3-7 contains the most recent detailed discussion of pneumonia. Although it repeats some information from earlier years, the most important warning, "It is inappropriate for coders to assume a causal organism on the basis of laboratory or radiology findings alone," merits repeating because it still remains an issue.
1) A patient presents with aspiration pneumonia and superimposed staphylococcal pneumonia. The patient aspirated food because of dysphasia due to a previous CVA. The condition resolved after treatment and the patient was discharge. How should this case be coded?
a. 507.0, 482.49; 438.82
b. 507.0; 438.82
c. 507.0, 482.40; 438.82
d. 482.40, 438.82
2) A patient is admitted to the emergency department (ED) from the SNF because of possible pneumonia. The patient was admitted to the hospital and put on a respirator. It was determined that the patient has severe sepsis due to the pneumonia with resulting respiratory failure. How should this case be coded?
a. 486; 038.9; 995.92; 518.81
b. 038.9, 995.91, 518.81, 486
c. 518.81, 486, 038.9, 995.92
d. 038.9, 995.92, 518.81, 486
3) A patient is admitted to the hospital with fever, shortness of breath and productive cough. Chest X-ray showed infiltrate involving the left lower lobe. The physician documents mixed bacterial pneumonia on discharge. How should this case be coded?
4) The patient is an 85-year-old female who presents to the ED with increasing shortness of breath, productive cough and progressive weakness. The patient was intubated, mechanically ventilated and started on broad-spectrum antibiotics for septic shock, respiratory failure and Hemophilus influenza pneumonia. The patient then suffered an acute nontransmural myocardial infarction (MI). How should this case be coded?
a. 038.9, 995.92; 785.52, 482.2, 518.81, 410.71, 96.72, 96.04
b. 482.2, 785.52, 410.71, 96.72, 96.04
c. 785.52, 482.2, 410.71, 96.72, 96.04
d. 038.9, 995.92; 482.89, 518.81, 410.71, 96.72, 96.04
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services at HSS, an Ingenix company (www.hssweb.com). HSS specializes in software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
Answers to CCS PREP!: 1. c. It is correct to code aspiration pneumonia along with a code for bacterial pneumonia when documented. Code 507.0 is assigned to identify the pneumonia due to aspiration of food, and code 482.40 is assigned to identify the pneumonia due to unspecified staphylococcus. Code 438.82 may also be assigned to report the dysphasia may have contributed to the aspiration pneumonia; 2. d. Code 038.9 is assigned to identify the severe sepsis. Code 995.92 is assigned instead of code 992.91 to identify SIRS due to infectious process with organ dysfunction. The respiratory failure, which is the organ dysfunction, is coded to 518.81. Because the type of pneumonia is unknown it is coded to 486, Pneumonia, organism unspecified; 3. b. Assign code 482.9, Bacterial pneumonia, unspecified, when the physician indicates mixed bacterial pneumonia and the organism is not specifically specified. If the physician had documented two or more specified organisms, all types of pneumonia should be coded; 4. a. Because the septic shock was present on admission and meets the definition for severe sepsis, assign 038.9, Unspecified septicemia, as the principal diagnosis. When septic shock is documented, it is necessary to code first the initiating systemic infection or trauma, in this case 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction; followed by code 785.52, septic shock. Code 482.2, Pneumonia due to Hemophilus influenzae; 518.81, Acute respiratory failure; and code 410.71, Acute myocardial infarction, Subendocardial infarction, initial episode of care, should be assigned as additional diagnoses. Assign code procedure code 96.72, Other continuous mechanical ventilation for 96 consecutive hours or more, and code 96.04, Insertion of endotracheal tube, for the procedures performed.