Part B Insider (Multispecialty) Coding Alert

Published on Fri Aug 12, 2011 PDF

Question: My physician documented "multilobar pneumonia." Which ICD-9 code should I report?

Answer: When coding for pneumonia, you should be able to identify the specific type, and code based on the causal organism. The Coding Clinic emphasizes that the term "lobar pneumonia" is, in fact, outdated as it codes only to 481 (Pneumococcal pneumonia [streptococcus pneumoniae pneumonia]), whereas other organisms may be involved. For instance, lobar pneumonia and pneumonia of the right lower lobe are not the same.

You would code Pneumonia of the right lower lobe without specification with 486 (Pneumonia organism unspecified), while lobar pneumonia is associated with pneumococcal pneumonia or organism unspecified pneumonia.

Important: If the physician uses nonspecific language, for instance 'healthcare-associated pneumonia' or 'nosocomial pneumonia,' you should clarify with him the specific bacterial type of the pneumonia. In addition, it might be a good time to schedule a brief documentation meeting with all of your practitioners to ensure that they are properly documenting diagnoses. Remind them that accurate documentation will be more important than ever as the medical industry is on the cusp of ICD-10, and let them know that it saves everyone time (and brings in money faster) down the road if you can code charts quickly based on their documentation.