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Pneumonia Coding in FY2020

Post by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10- CM/PCS Trainer.

We hear a lot about the incidence of Pneumonia in the general population, especially in the winter months. We also find this diagnosis in many settings all across healthcare, not just inpatient. The clinical coding of this condition involves understanding the clinical aspects as well as the specific coding guidelines.

CLINICAL OVERVIEW: Before we discuss the ICD-10-CM coding of pneumonia diagnosis, we need to first have a clear understanding of the many clinical aspects and indicators that help to tell us if a patient might have this condition. Currently, over 3 million people develop pneumonia each year in the United States. Over half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

When we think of “Pneumonia” we think about the lungs. The lungs are the primary organ of the respiratory system. Humans have two lungs (right and left) with a total of 5 sections or lobes. The left lung has two lobes and the right lung has three. The lung air sacs become inflamed when we have Pneumonia. This inflammation can be caused by bacteria, virus, fungi, parasites or even via aspiration. Bacterial and fungal pneumonia is most often identified through a sputum culture.

Lobar pneumonia typically involves a consolidation of one or more lobes of the lung. The most common cause of lobar pneumonia is Streptococcus pneumoniae (pneumococcus). Other common types of bacteria responsible for “lobar” pneumonia are:

  • Klebsiella pneumoniae

  • Legionella pneumophila

  • Haemophilus influenza

  • Mycobacterium tuberculosis

  • Bacterial pneumonia

Patients with Pneumonia will typically have any of the following symptoms:

  • Cough

  • Fever

  • Chest pain when breathing or coughing

  • Chest rales

  • Chills/Sweating

  • Shortness of Breath

  • Tired/Fatigue

  • Nausea

  • Mental Confusion (seen in those over 65 yrs.)

ICD-10-CM OVERVIEW: The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) AND follow Official Guidelines, which can be located at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf.

Guidance and direction published in the American Hospital Association ICD-10-CM/PCS Coding Clinic should also be adhered to. ICD-10-CM Chapter 10 Diseases of the Respiratory System (J00-J99), is where you can locate the specific guidelines relating to the coding of Pneumonia; all should be reviewed and followed.

NOTE: When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site e.g. tracheobronchitis to bronchitis in J40. For coding conditions from Chapter 10, the following applies to all codes J00-J99:

Use additional code, where applicable, to identify:

  • Exposure to environmental tobacco smoke (Z77.22)

  • Exposure to tobacco smoke in the prenatal period (P96.81)

  • History of tobacco use (Z87.891)

  • Occupational exposure to environmental tobacco smoke (Z57.31)

  • Tobacco dependence (F17.0-)

  • Tobacco use (Z472.0)

The specific type of Pneumonia or causal organism drives the coding classification selection. Chapter 10 of ICD-10-CM the classification of Pneumonia falls into the following categories:

  • J12 Viral pneumonia, not elsewhere classified

  • J13 Pneumonia due to Streptococcus pneumoniae

  • J14 Pneumonia due to Hemophilus influenzae

  • J15 Bacterial pneumonia, not elsewhere classified

  • J16 Pneumonia due to other infectious organisms, not elsewhere classified

  • J17 Pneumonia in diseases classified elsewhere

  • J18 Pneumonia, unspecified organism

  • J69 Pneumonitis due to solids and liquids

There also are a few types of pneumonia found in Chapter 1, such as: Pneumonia due to anthrax A22.1, Pneumonia due to Chickenpox B01.2 and Pneumonia due to Candidiasis B37.1.

For ventilator associated pneumonia, there is a specific code to report in ICD-10-CM:

J95.891 Ventilator associated pneumonia

An additional code is assigned to identify the organism, is known i.e.., B95.-, B96.-, B97.-. Review the documentation carefully to confirm the pneumonia is ventilator associated and if needed query the provider as to whether the pneumonia is a complication attributed to the mechanical ventilator.

ICD-10-CM coding related to e-cigarette, or vaping, product use associated lung injury (EVALI) and assign the code for the specific condition, such as:

  • J68.0, Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis

  • J69.1, Pneumonitis due to inhalation of oils and essences; includes lipoid pneumonia

  • J80, Acute respiratory distress syndrome

  • J82, Pulmonary eosinophilia, not elsewhere classified

  • J84.114, Acute interstitial pneumonitis

  • J84.89, Other specified interstitial pulmonary disease

It should be noted that as of September 2019 a new code U07.0, Vaping-related disorder, was released.

A diagnosis of Pneumonia may be assigned as a principal diagnosis and one should review carefully the circumstances of admission for a hospital inpatient encounter. Also apply the definition of a principal diagnosis, “when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List”. However, chapter specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

Follow the Official Guidelines for Reporting an “additional diagnosis” (Section III) for both inpatient coding and Section IV for outpatient coding.

There are times when the provider will need to be queried regarding their documentation, and we must follow the AHIMA/ACDIS Practice Brief regarding “Guidelines for Achieving a Compliant Query” and the AHIMA “Standards of Ethical Coding”.

REMEMBER:

  • As of October 1, 2019, if pneumonia is documented as affecting a particular lobe, it is coded to J18.9, Pneumonia and NOT J18.1

  • The code for the systemic infection should be assigned first, followed by a code for the localized infection (for example pneumonia);

  • There are several ICD-10-CM codes for the different types of Pneumonia, review the clinical documentation carefully, you may need to query the provider for clarification;

  • The most common cause for lobar pneumonia is Streptococcus pneumoniae (pneumococcus).

Be sure to sign up for our upcoming webinar: Respiratory Trio: Respiratory Failure, Pneumonia, and COPD Coding

References:

 
Robyn Petersendocumentation, coding guidelines, icd-10, respiratory, pneumonia