Home Health ICD-9/ICD-10 Alert
Know When--And How--To Report Pneumonia
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Question: We have a patient who came to us from the hospital after a bout with aspiration pneumonia. While in the hospital she had a gastrostomy tube inserted. We supplied IV antibiotics for three days after she returned home. After she was disconnected from the IV and began receiving an antibiotic by mouth, she spiked a fever.
She returned to the hospital after four days at home. She was diagnosed with dysphagia, pneumonia, hypertension, depression, and hypothyroidism. Skilled nursing will be observing for complications and providing additional teaching on the care of the gastrostomy; speech therapy will be visiting for treatment of the dysphagia. How should I code for her? I am especially curious to know whether we should code for pneumonia or if that should be considered resolved.
New Jersey Subscriber
Answer: If the patient is still on antibiotics for the pneumonia, you may still code for the pneumonia with the appropriate code from the 480-487 (Pneumonia and influenza) category. If not, you may consider V12.61 (History of pneumonia [recurrent]). Don't let the "recurrent" term trip you up ...quot; it's a non-essential modifier, so the pneumonia doesn't have to be recurrent for you to use the code.
Considering that the dysphagia seems to be part of the plan of care for both nursing and speech therapy, the dysphagia may be the appropriate primary diagnosis, if the pneumonia is resolved.
Home Health ICD-9/ICD-10 Alert
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