Pulmonology Coding Alert

Rule out alternate diagnoses before documenting VAP. 

Ventilator associated pneumonia (VAP) is a very specific form of pneumonia. If the pulmonologist diagnoses it in a patient, you have to back it up with enough documentation to support the diagnosis, as differentiating the disease from other respiratory complications is a difficult task. ICD-9 made a provision for coding this condition by separating it from unspecified pneumonia category and ICD-10 continues to support VAP diagnosis with a direct cross over from ICD-9.

Background: Collected data show that pneumonia is the second most common nosocomial infection in critically ill patients, and may affect 27 percent of all critically ill patients. Eighty-six percent of nosocomial pneumonias are associated with mechanical ventilation and are termed ventilator-associated pneumonia (VAP). A VAP is a lung infection or pneumonia that develops in a person who is on a ventilator, a machine that helps a patient breathe by giving oxygen through a tube that can be placed in the patient’s mouth, nose, or through a hole in the front of the neck. The infection may occur if germs enter through the tube and get into the patient’s lungs.

You’ll base your code on the provider’s documentation and should only assign it when the provider has documented the presence of VAP. ICD-9 stipulates that an additional code should be included along with the primary code to identify the organism responsible, if known, for the VAP. Usually in VAP cases, infections are due to gram negative organisms, such as Pseudomonas, or staph (e.g., Pseudomonas aeruginosa, Acinetobacter spp., Stenotrophomonasmaltophilia etc.). In ICD-9, you currently use 997.31 (Ventilator associated pneumonia), under the 997 (Complications affecting specified body systems, not elsewhere classified) category. The code directly crosses over to the ICD-10 code J95.891 (Ventilator associated pneumonia) under the broader category J95 (Intraoperative and postprocedural complications and disorders of respiratory system, not elsewhere classified). 

Note: You should make sure that the provider has ruled out all alternate diagnoses before documenting VAP. Conditions such as heart failure, hemorrhage, acute respiratory distress syndrome (ARDS), nosocomial tracheobronchitis, and influenza can all look like VAP.

Example 1: A patient develops pneumonia after being on the ventilator for 72 hours. Your pulmonologist orders diagnoses VAP after documenting new and progressive radiographic infiltrates, a blood leukocyte count of >10,000 cells/ml and purulent tracheal secretions after interpreting test results. The physician notes the causative agent as Pseudomonas aeruginosa.

You will currently code this as:

• 997.31 and
• 041.7 (Pseudomonas infection in conditions classified elsewhere and of unspecified site) 

In ICD-10, you will code it as:

• J95.891 and 
• B96.5 (Pseudomonas [aeruginosa][mallei] [pseudomallei] as the cause of diseases classified elsewhere).

Other possible scenarios can be:

• 997.31 and 041.11 (Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site), which will convert to J95.891 and B95.61 (Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere) in ICD-10
• 997.31 and 041.12 (Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site) that will translate under ICD-10 to J95.891 and B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere).

Example 2: A patient is diagnosed with ventilator associated pneumonia due to Klebsiellapneumoniae. You currently assign code 997.31 and code 041.3 (Klebsiella pneumonia). In ICD-10, you will code J95.891 and B96.1 (Klebsiellapneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere).

Note: Do not assign a code from categories 480-484 for the pneumonia if the physician has confirmed VAP. Look for terms such as “mechanical ventilation is the cause of pneumonia,” “ventilator acquired,” or “ventilator associated” in the accompanying documentation.