With the Patient-Driven Payment Model (PDPM) coming down the pike, understanding ICD-10 coding will be crucial to gaining your facility’s hard-earned reimbursement. That’s why we’ve promised to help prep your team by providing regular ICD-10 coding tutorials right here (so be sure to bookmark our blog and visit often).
In today’s post, we’ve decided to break down pneumonia coding. Given the vast number of ICD-10 codes for pneumonia — 75 to describe various forms and causes within the adult population — we suspect you might feel somewhat intimidated. Fear not, though. We’re about to dislodge your uncertainties with solid pneumonia coding know-how.
Pneumonia can arise from respiratory infections with causes determined to be bacterial, viral, iatrogenic, fungal, parasitic, resulting from aspiration, etc.
In nursing facilities, the most common pneumonias encountered are bacterial, viral, or caused by aspiration or procedure complication (iatrogenic). This information likely provides a good starting place for SNF physicians seeking to diagnose a resident’s form of pneumonia. Similarly, these common causes of pneumonia are worth keeping in mind when coding a resident’s condition.
Naturally, figuring out the precise cause of pneumonia informs your staff on how to proceed with the resident’s treatment. Knowing the cause of pneumonia is equally crucial to selecting the correct ICD-10 code for the provider’s diagnosis.
There are numerous codes for pneumonia caused by bacteria, which you can find in code category J15.
For you to choose the correct code from the 13 possible code options, you’ll need to know the exact causative organism, such as Klebsiella, Pseudomonas, staphylococcus, staphylococcus, streptococci, and Escherichia coli.
Example: A physician diagnoses a resident with pneumonia, along with an abscess in the right lung. The reports show the causative organism is Klebsiella pneumoniae. How do you code for this situation?
Pneumonia due to Klebsiella is a diagnosis that might seem fairly easy to code, but proceed with caution. There is indeed a dedicated code for this case (J15.0, Pneumonia due to Klebsiella pneumoniae), but you will need to be careful because you need to code the associated abscess first: J85.1 (Abscess of lung with pneumonia).
That’s not all: Before picking a bacterial pneumonia code and washing your hands of coding this case, you need to remember that CMS guidance says that if the resident happens to have associated viral influenza as well, you need to report that with J09.X1 (Influenza due to identified novel influenza A virus with pneumonia), J10.00 (… other identified influenza virus with unspecified type of pneumonia), or J11.00 (… unidentified influenza virus with unspecified type of pneumonia).
You will also need to be aware of code options for pneumonia due to viral causes. While Category J12 talks of viral pneumonias such as SARS and syncytial virus, categories J10 and J11 have codes for an influenza with associated pneumonia.
Example: Let’s tackle another case. A resident has influenza with pneumonia, and the provider documents the presence of novel influenza A virus and parainfluenza virus. How do we code this?
You do have a specific code J12.2 (Parainfluenza virus pneumonia). However, we will need to first report the influenza A virus. So, the first code would be J09.X1 (Influenza due to identified novel influenza A virus with pneumonia).
In nursing facilities, you know that residents who require assistance with foods or fluids may be especially at risk for aspiration pneumonia. There’s a dedicated category J69.- (Pneumonitis due to solids and liquids), but you will need to be careful in picking the exact code here as well.
Example: A physician comes across a case of inhalation of regurgitated food. The physician finds the presence food particles in the trachea, and resident has aspiration pneumonia. Here you might use J69.0 (Pneumonitis due to inhalation of food and vomit) as it covers aspiration pneumonia due to food regurgitation, gastric secretions, and vomiting, but it also requires you to code for an associated foreign body in respiratory tract (T17.-).
Pneumonia may ensue as a complication or result of a medical procedure. If the documentation suggests that the resident developed pneumonia during treatment while on a ventilator, you may assign the code J95.851 (Ventilator associated pneumonia). You will need to use an additional code to identify the organism, if known (B95.-, B96.-, B97.-).
At times, there may be an additional diagnosis such as sepsis (R65.2-) or respiratory failure (J96.-), for which you would need additional documentation.
Not all cases of pneumonia will result from the causes expected within your resident population, of course.
If you know that a resident’s pneumonia isn’t due to bacteria, a virus, or aspiration, you may need to look to other causative organisms, such as fungus, parasite, or mycosis. There are about 20 coding options to consider. The causative organism could be rubella, Salmonella, spirochete, actinomycetes amongst many others.
Print and refer to this handy chart for coding various pneumonia conditions that aren’t bacterial, viral, or due to aspiration.
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