Pulmonology Coding Alert

Tip: Put etiology at front for confirming diagnosis.

To successfully report embolisms, the embolism origin is the main deciding factor in choosing the primary diagnosis. However, code selection isn’t foolproof. Check out four possible places where you can slip and end up at the wrong end of claim rejections.

Pitfall 1: Septicemia isn’t Your Primary Diagnosis

You may be successfully identifying the exact embolism code, but if you report the embolism code as your primary code, you are fishing for trouble. Whatever the type of embolism you encounter, the golden rule is this: You always code the underlying cause of the embolism first and then the type of embolism.

Case: A 45-year-old patient with a history of heavy smoking presents to the pulmonologist with fever, shortness of breath, and pulmonary infiltrates, one of which has a small cavity in it. Blood culture reveals bacterium staphylococcusaureus, and the pulmonologist reports tricuspid endocarditis in his medical record. You should code 038.11 (Methicillin susceptible staphylococcus aureus septicemia) for the staphylococcal septicemia, 421.0 (Acute and subacute bacterial endocarditis) for acute bacterial endocarditis, which entails that you add code 041.11 (Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site) for identifying the infectious organism of the bacterial endocarditis, and 415.12 (Septic pulmonary embolism) for septic pulmonary embolism.

The case demonstrates that along with 415.12, you have to also report another code identifying the septicemia (038.0-038.9).

Note: If septic pulmonary embolism (SPE) also causes a subsequent lung abscess or necrotizing pneumonia, you should code that condition as well. Report either the lung abscess or necrotizing pneumonia as 513.0 (Abscess of lung).

Pitfall 2: You Mistake ‘Arterial’ Embolism for ‘Pulmonary’

If you find it difficult to differentiate between the two main types of septic embolism, look at the medical record to find the embolus’s origin and the final location. 

Arterial: A septic arterial embolus may originate from a central infection, such as in the heart (for instance, infective endocarditis, primarily left-sided). The embolic material travels through the systemic arterial system to lodge in small vessels anywhere in the body, such as the brain, the retina, or the digits.

Pulmonary: On the other hand, a septic pulmonary embolus will originate from a localized infection such as a localized cellulitis or a central venous catheter infection. The embolic material travels through the venous system to the right side of the heart and goes into the pulmonary arterial system where it lodges in small vessels.

You will never go wrong if you have captured two facts correctly from the physician’s medical records –whether the emboli has been described as “septic” and the embolism’s “location.” If you can’t confirm both these facts from the physician’s clinical documentation, then you should go through additional reports or diagnostic studies (such as blood cultures, chest computed tomography, chest X-ray, or transesophageal echocardiography) that demonstrate and confirm the presence of multiple, nodular lung infiltrates in the periphery of the lung, with or without cavitation.

Real life scenario: A patient would often have an indwelling catheter or device and would typically present with insidious onset of fever and respiratory symptoms. In this scenario, make sure you gently persuade the physician to document the diagnosis to the highest specificity of the patient’s condition. This will save you later headaches while billing for the hospital’s claims as well as the physician’s professional services.

Pitfall 3: You Ignore 449 for Septic Arterial Embolism

Once you have correctly established that the diagnosis is of a septic embolism of the “artery,” you can safely code the condition specifically with 449 (Septic arterial embolism), which describes a septic embolism of any artery.

You have to remember that you’ll never use 449 as the primary code. When a pulmonologist diagnoses a patient with septic arterial embolism, you will first code the underlying infection, such as infective endocarditis (421.0) or lung abscess (513.0).

Case: A patient with bacterial endocarditis develops a cold lower extremity due to an arterial thrombosis originating from the heart. You would code 421.0, 449, and 444.22 (Arterial embolism and thrombosis of lower extremity) for the specific site of the embolism.

Pitfall 4: You Aren’t Using the Septic Pulmonary Embolism Code

You may be missing out on deserved reimbursement if you are not using the fifth digit “2” enough in the subcategory 415.1x (Pulmonary embolism and infarction) of ICD-9 list enough. That’s right, you may be still be using an “other specified” code for septic embolism instead of the specific code 415.12.

Just make sure that you have pinpointed the primary condition first and also confirmed that there is no chronic pulmonary embolism (416.2, Chronic pulmonary embolism) mentioned in the physician’s medical record. 

Finally, if you still end up with a pulmonologist’s note that mentions non-identification of the septic embolism type, you can always revert safely to 415.12 forseptic embolism not otherwise specified (NOS).