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clinical pneumonia

  1. #1
    Red face clinical pneumonia
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    Hi can any tell me if I can code a dx of clinical pnuemonia as 486? Some say this is not a dx. Thanks for any help.

  2. #2
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    Unfortunately, if the Doctor's don't specify what type of Pneumonia it is, you have no choice but to use the 486. We have the same problem with our Docs.

  3. #3
    Location
    Torrington
    Posts
    20
    Smile
    I would be comfortable coding 486 as long as he was treating this patient with an antibiotic.

  4. #4
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    I do a lot of ER coding and I also have a problem with the doc's writing anything more than pneumonia. Sometimes they will specify LLL or something like that but for the most part, we end up using the 486 code the most.

  5. #5
    Default
    Thank you all so much.

    I guess there were issues with the fact the dr. states its "clinical" pna. Some people were saying that clinical means the same as possible and we cant code possible dx. I just think it means the dr. make an educated guess that the pt has pna. ANy thoughts on this?

  6. #6
    Default pneumonia
    LLL is lobar pneumonia and should be coded 481

  7. #7
    Default
    Yes, I am aware of that. I was just letting her know that UNLESS they state LLL or another type of pneumonia, to use the 486.

    As far as your question Dawn, I would only code what it documented. I think you are right NOT to code anything that is "possible" or "probable" but if the physician makes that assumption and documents it that way and treats as clinical pneumonia, then you can code it that way. As long as it doesn't state possible. Good luck

  8. #8
    Location
    Columbia, MO
    Posts
    12,570
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    Physicians are allowed to diagnose infective type conditions such as pneumonia, UTI, Strep, Sepis, etc based on the patient's clinical presentation, and they do not require any diagnostic evidence to support the diagnosis. Therefore it looks to me like that is maybe what this physician was taught to write when he renders a clinical assessment of pneumonia without diagnostic support, so I have no problem with the 486 code.
    Debra Mitchell MSPH, CPC-H

  9. #9
    Default
    Thank you debra and leslie I feel more comfortable about this now. sometimes you just need a sane mind to agree with you

  10. #10
    Default
    Quote Originally Posted by sherryc View Post
    LLL is lobar pneumonia and should be coded 481

    Some one correct me if I am wrong but i believe that when a dr writes LLL this is just indicating the place where the pna is not a dx for lobar pna. The code for lobar pneumonia "481" refers to the "type" of pneumonia, not the "site".

    Dawn

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