Tuesday, December 1, 2020

Ventilator Associated Pneumonia

Ventilator associated pneumonia (VAP) is the topic for this installment of “In the kNOW.” Ventilator associated pneumonia occurs 48 hours after a patient has been intubated and placed on a ventilator.  Typically, patients who acquire VAP will be in an intensive care unit.  Coding professionals must use care when assigning the code for VAP as various circumstances can impact the codes assigned.  Let’s look at those now.

If a patient has pneumonia and is placed on a ventilator, that does not mean the pneumonia is a VAP.  If the pneumonia is pre-existing and the patient is placed on a ventilator for management, then the pneumonia should be coded to the specific type, if known.  For example, bronchopneumonia with ventilator management will be coded to J18.0.  Otherwise, the code will be pneumonia, unspecified organism at J18.9.     

In circumstances where the provider documents VAP, the code J95.851 for ventilator associated pneumonia is assigned.  An additional code is required to identify the organism if it is known.  This code would come from the B95-B97 categories of codes.  It is inappropriate to assign a code from J12-J18 as a way to capture the specific type of pneumonia.  An example of the proper code assignment for VAP due to E. Coli is J95.851 and B96.20 and not J15.5.

Coding professionals should not assume that a patient with pneumonia on a ventilator has VAP.  When the provider has not specifically documented ventilator associated pneumonia and there is concern that such a complication exists, the coding professional must query the provider for clarification.  
Bear in mind that a patient may be admitted with pneumonia (12-J18) and subsequently develop VAP.  In that circumstance, it is appropriate to code the VAP as a secondary diagnosis as long as it has been properly documented. 

Let’s also take a moment to look at coding for COPD with VAP.  Since the VAP is not considered a lower respiratory infection but rather, is located under intraoperative or postprocedural complications and disorders of respiratory system, not elsewhere classified, the correct code assignment would be J44.9 and J95.851.  Do not use J44.0 as that code specifically indicates the COPD with a lower respiratory infection. 

you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

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.