Pulmonology Coding Alert

CD-9 2008 will give you one more choice in the commonly reported 415.1x subcategory

When two septic embolism ICD-9 codes debut this fall, you'll have to relegate the codes to at least Dx2 and choose the right diagnosis based on the disease's origin.

Grant Septic Pulmonary Embolism Its Own Code

ICD-9 2008 will add one code to 415.1x (Pulmonary embolism and infarction). As of Oct. 1, 2007, you will be able to indicate "septic pulmonary embolism" with 415.12.

Good news: You'll be able to specify this disease, rather than having to lump it under an "other specified" code. ICD-9 2007 contains no entry for embolism, septic. "Septic pulmonary embolism currently would be coded to 415.19 (... other), along with codes for septicemia and sepsis, as appropriate," according to the ICD-9-CM Coordination and Maintenance Committee Meeting Sept. 28-29, 2006, Diagnosis Agenda.

Always Code Septicemia as Primary

When 415.12 becomes valid, the "code also" instructions will remain intact. You will still first code the underlying infection, such as septicemia (038.0-038.9).

Example: A 24-year-old IV drug abuser enters the hospital with fever, shortness of breath and pulmonary infiltrates, one of which has a small cavity in it. Staphylococcus aureus is cultured from the blood, and the pulmonologist diagnoses tricuspid endocarditis. "You would code 038.11 for the staphylococcal septicemia, 421.0 for acute bacterial endocarditis, 041.11 for staphylococcus aureus, and 415.12 for septic pulmonary emboli," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

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

Use 449 for Any Septic Arterial Embolism

Thanks to an additional request from the Coding Clinic's Editorial Advisory Board, you can look forward to the introduction of one more septic disease. ICD-9 2008 will also debut new code 449 for "septic arterial embolism."

Change: Starting Oct. 1, you'll classify the disease to a whole new subcategory. Septic arterial embolism now falls under 444.9 (Arterial embolism and thrombosis; of unspecified artery).

And the singular code 449 will describe a septic embolism of any artery. National Center for Health Statistics (NCHS) staff had proposed to add five codes to the subcategory, which would allow you to specify the artery. But after commenters questioned the need for these codes, the Centers for Disease Specialists decided to consolidate the disease under one code.

Restrict Arterial Embolism to Secondary Dx

Just like 415.12, you'll never use 449 in the primary position. When a pulmonologist diagnoses a patient with septic arterial embolism, you will first code the underlying infection, such as infective endocarditis (421.0, Acute and subacute bacterial endocarditis).

Lock in Type With Disease's Origin

Not sure of the difference between the two main types of septic embolism? The keys are where the embolus starts and ends up. "A septic arterial embolus may originate from a central infection, such as in the heart" (for instance, infective endocarditis, primarily left-sided), according to the ICD-9 diagnosis agenda. 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.

In contrast, a septic pulmonary embolus can 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.

Tip: When you review the pulmonologist's documentation, look for two details:

• the embolism's location

• a description of the embolus as "septic."

If the chart lacks either piece of information, you may "review additional reports or diagnostic studies (such as blood cultures, chest computed tomography, chest x-ray or transesophageal echocardiography) that confirm the presence of multiple, nodular lung infiltrates in the periphery of the lung, with or without cavitation," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. The patient often has an indwelling catheter or device and typically presents with insidious onset of fever and respiratory symptoms.

For patients who fit this clinical picture, educate the physician regarding documentation to the highest specificity of the patient's condition. "This will support not only the claims for the physician's professional services but also the hospital's claims," Pohlig says.

Revert to 415.12 When Type Is Unidentifiable

If the pulmonologist can't identify the septic embolism type, don't fret. ICD-9 2008 will offer you an easy out. Septic embolism not otherwise specified (NOS) will be classified to 415.12. Pulmonary is the most common site, explained NCHS staff in the ICD-9-CM Coordination and Maintenance Committee Meeting Sept. 29, 2006, Summary.

Go With Symptoms Until SPE Is Diagnosed

Don't be surprised if you start coding a patient with 415.12 after initially using a diagnosis of pulmonary embolism or signs and symptoms. Septic pulmonary embolism is difficult to diagnose, says Jay H. Ryu, MD, Division of Pulmonary and Critical Care Medicine at the Mayo Clinic in Rochester, Minn.

In a study of the disease published by the American College of Chest Physicians (www.chestjournal.org/cgi/content/abstract/128/1/162), Ryu along with co-authors found the median duration of symptoms including fever (780.6), dyspnea (786.09, Dyspnea and respiratory abnormalities; other), pleuritic chest pain (786.52, Chest pain; painful respiration), sore throat (462, Acute pharyngitis), cough (786.2) and hemoptysis (786.3) before diagnosis of SPE was 18 days, and the median duration of hospitalization before the SPE diagnosis was three days (range, zero to 15 days).

Do this: ICD-9 guidelines don't allow you to code "rule outs," "probables" or "possibles," says Vicky V. O'Neil, CPC, CSS-P, president of The Hazlett Group in St. Louis. "You should code signs and symptoms until the diagnosis is definitive," she says.

Alternative: If the pulmonologist initially diagnoses pulmonary embolism and diagnoses SPE later in the hospital stay, use 415.19 for other pulmonary embolism with the visits performed before the confirmation of sepsis. Then when the pulmonologist diagnoses septic pulmonary embolism, assign 038.x and 415.12 for SPE.