Remember the phrase “Round and round she goes, and where she stops nobody knows”? Well, that’s how I feel when considering coding direction related to lobar pneumonia. It seems we are on a merry-go-round and just when we think it is safe to get off, it picks up speed and keeps going. So let’s review coding of lobar pneumonia discussed in the first blog which was posted on this topic last March and then examine the subsequent advice change.
(Original blog post)
Change - a concept with which coding professionals are all too familiar. This “In the kNOW” delves into an example of why it is so vital to constantly update a coding professional’s knowledge base by examining the diagnosis of lobar pneumonia and reviewing relevant Coding Clinics related to that diagnosis.
Lobar pneumonia is type of pneumonia that affects an entire pulmonary lobe or multiple lobes of the lung. In the vast majority of cases, lobar pneumonia is caused by Streptococcus pneumonia. As such, initial guidance from Coding Clinic back in 1985 instructed coders to code the diagnosis of lobar pneumonia to pneumococcal pneumonia, which under ICD-9 coded to 481 and under ICD-10 codes to J13.
Fast forward to 2009, when another question surfaces, this time regarding the appropriate coding for multilobar pneumonia. Now coding professionals are instructed to query the physician for the specific type of pneumonia. If no further clarification is obtained, then the code to be used is 486 (ICD-9) (J18.9 ICD-10) for an unspecified pneumonia. It had been determined that the term “lobar pneumonia” was outdated, and that lobar pneumonia actually had many causes not just pneumococcal (which traditionally affected one lobe but could encompass several lobes).
In a recent 3rd Qtr. 2018 update, Coding Clinic once again addressed the coding for a lobar pneumonia diagnosis. Guidance provided that when a diagnosis of “lobe pneumonia” (such as left lower lobe pneumonia) was documented, it is to be considered lobar pneumonia and coded to J18.1. This is true regardless of whether the documentation indicates one lobe, multiple lobes, or a partial lobe are impacted.
Code J18.1 is specific to the location of the pneumonia rather than the causative organism. Should the documentation further specify the agent responsible, then there are combination codes available under “Pneumonia, lobar” in the Alphabetic Index to capture that information. For example, E. coli lobar pneumonia codes to J15.5.
Assignment of J18.1 for the unspecified lobar pneumonia results in the MS-DRG of 195-Simple Pneumonia and Pleurisy w/o CC/MCC with a reimbursement weight of 0.6868. Hemophilus influenzae, pneumococcal, streptococcal, or specified organism NEC types of lobar pneumonia will all fall into the same MS-DRG of 195. Note that Klebsiella pneumoniae, Pseudomonas, Escherichia coli, and Proteus specific lobar pneumonias will result in assignment to MS-DRG 179-Respiratory Infections and Inflammations w/o CC/MCC with a reimbursement weight of 0.9215.
This brings us back to querying the physician. While it is possible to code lobe or lobar pneumonia, there is the potential for increased reimbursement as illustrated above, should the physician be able to specify the exact type of pneumonia. Therefore, it may be beneficial for a coder to query the physician for the exact type of lobar pneumonia affecting the patient.
Review of this one diagnosis, lobar pneumonia, is just one incidence of the changes that coding professionals see on a frequent basis. A coder can never assume that information learned years ago is still relevant today. Medicine is changing it an ever-increasing speed, in turn influencing how we code. It is our responsibility to maintain a commitment to life-long learning to ensure we keep up with those changes.
The last paragraph in the original blog is so true and how quickly another change has come. A correction to lobar pneumonia coding was published in the 3rd Qtr. 2019 Coding Clinic. Now coding professionals are instructed that the diagnosis must be specific to “lobar” pneumonia in order to assign code J18.1. Documentation of pneumonia in one lobe or multiple lobes is NOT to be coded to “lobar” pneumonia without that term being specified by the provider. Clarification states that lobar pneumonia represents a consolidation of an entire lobe rather than just infiltrates and that it would not be appropriate to assign lobar pneumonia if imaging shows pneumonia in one or multiple lobes.Now you are In the kNOW!!
About the Author
She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.