Careful Pneumonia Coding Helps To Keep Provider-payer Relationship Healthy

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Pneumonias are differentiated by clinical findings along with findings on physical examination; as such coding the specific condition could be a tricky affair. If a claim confirms pneumonia for a patient who presented with symptoms, do you know what to do with the results?


Take a look at this scenario: A patient treats a pulmonologist who orders a chest x-ray because of a persistent cough. The consequence of the chest x-ray points out that the patient has pneumonia. A pulmonologist carries out a sputum culture, and confirms the Eaton's agent pneumonia -- a type of pneumonia caused by the organism mycoplasma pneumoniae. The interpreting physician should report a primary diagnosis of pneumonia.


Well, not so fast. The ICD-9 lists various classifications of pneumonia that covers 480-486 of the manual. In fact, overuse of the diagnosis codes for specified bacteria has been rampant among coders of pulmonology. You shouldn't be part of the statistics. Debunking these two myths could protect you from a possible denial.


One pneumonia code fits all


The ...
... clue to a successful claim for pneumonia is in your physician's final diagnosis. This diagnosis should specify what organism lead to the pneumonia. If you have a difficult time deciding on the final diagnosis, you can always enquire your physician for further details.


Keep in mind: If your doctor's notes simply read 'pneumonia', it is not sufficient. You should enquire the physician if there's a confirmed cause of the condition. For example, the diagnosis tests results in the above-mentioned scenario are very clear on what organism lead to the pneumonia: Mycoplasma pneumonia. As such, you should bill the condition with 483.0.


Diagnostic workup normally includes chest x-rays, and blood and sputum cultures. If the doctor does not identify a causal organism such as staphylococcus or streptococcus, you would use code 486.


Warning: You should tread carefully when coding 486 when there is clinical evidence of a more specific type of pneumonia being treated. Even though this is a very common pneumonia code, asking the doctor to clarify unclear, ambiguous, or inconclusive still works best.


In its Second Quarter 1998 release, the American Hospital Association's Coding Clinic provides the following guidelines for coding pneumonia:


Do not assume
Do not assign codes based on lab or x-ray


It is not proper for coders to assume a casual organism on the basis of laboratory or radiology findings alone.


Patient symptoms do not tell you anything


Patients with bacterial pneumonias many a time present symptoms such as chronic cough (786.2, Cough), fever with chills (780.60, Fever, unspecified), and chest-wall pain (786.52, Painful respiration). You can't identify bacterial pneumonia based merely on sputum culture or assigning code 482.89 (Pneumonia due to other specified bacteria).


If the physician documents bacterial pneumonia without further specification, you should talk to her for clarification. If you cannot find further documentation, you should bill the diagnosis with 482.9 (Bacterial pneumonia, unspecified).


For more on this and for other specialty-specific articles to assist your pulmonology coding, sign up for a good medical coding resource like Coding Institute.