Lobar Pneumonia Revisited

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  It had been determined that the term “lobar pneumonia” was outdated, and that lobar pneumonia actually had many causes not just pneumococcal (which traditionally affected one lobe but could encompass several lobes).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 3^rd 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. 

(Newest Revision)

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 3^rd 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 

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.

Coding Heart Failure

This installment of “In the kNOW” is going to review recent Coding Clinic information related to the coding of heart failure.  First, let’s review heart failure in general noting that there are three types of heart failure: left-sided, right-sided, and congestive.

In left-sided heart failure, the blood is not pumped out to the rest of the body efficiently causing the left ventricle to work harder to supply blood flow.  There are two types of left-sided heart failure: heart failure with reduced ejection fraction (HFrEF)(systolic), and heart failure with preserved ejection fraction (HFpEF)(diastolic).  The ejection fraction is a measurement (percentage) of how much blood is being pumped out by the left ventricle with each contraction.  Normal ejection fractions generally run between 50%-70%.  In heart failure with preserved ejection fraction, contraction of heart muscles is normal, but relaxation of the ventricles is abnormal due to stiffness, thus limiting the amount of blood that can fill the heart.  In heart failure with reduced ejection fraction, the contraction part of the process is abnormal and not enough blood enters the circulation.  Because the terminology of HFrER and HFpEF is more widely accepted now, coders may use those terms to assign codes for systolic or diastolic heart failure respectively or a combination of both if applicable.  Keep in mind that additional clarifying terms may impact code assignment, such as acute, chronic, or acute on chronic.   

                                    Acute                   Chronic           Acute on Chronic       Unspecified
Systolic                        I50.21                    I50.22              I50.23                           I50.20
Diastolic                       I50.31                    I50.32              I50.33                           I50.30
Systolic & Diastolic       I50.41                    I50.42              I50.43                           I50.40
Unspecified                                                                                                          I50.9

Left-sided heart failure is often the precursor for right-sided heart failure.  Failure of left ventricular function causes a back-up of pressure to the lungs and ultimately, the right side of the heart.  This domino effect continues with fluid backing-up in the veins.

Congestive heart failure (CHF) (I50.9) is manifested with swelling in bodily tissues, especially legs and ankles.  Shortness of breath may occur when fluid backs-up and collects in lung tissue (pulmonary edema).  CHF happens when the heart is not pumping out blood at a normal rate, and back-up into the veins occurs.  

It is important to note that the American Heart Association has established a classification system for heart failure, A-D.  Class or stage A means that objectively there is no evidence of cardiovascular disease, and that ordinary physical activity is not limited and does not produce any symptoms.  Bearing this in mind, Coding Clinic has indicated that it is inappropriate to code stage A heart failure to I50.9 as the patient does not yet have the disease, even though they have risk factors.  Coders are therefore instructed to use Z91.89, Other specified personal risk factors, not elsewhere classified, to indicate the increased risk status.  Additional codes could be assigned for other conditions which might factor into the risk level such as hypertension or coronary artery disease.

When systolic/diastolic dysfunction is noted along with congestive heart failure, there must be linkage in the documentation to assign systolic or diastolic CHF.  For example, if documentation states chronic CHF with systolic dysfunction, the provider has indicated a relationship using the term “with” so code I50.22 can be assigned.  If on the other hand, the provider stated chronic CHF and systolic dysfunction, there is no linkage and only code I50.9 can be assigned.

Finally, coders have been instructed to assign I11.0 (hypertensive heart disease) in conjunction with an I50.- (heart failure) code to correctly code hypertension and heart failure even in the absence of provider documentation specifically linking the two conditions.  Coders are reminded that there is a presumptive relationship between hypertension and heart involvement, and that these conditions should be coded using the combination code of I11.0 and then the appropriate heart failure code by following the “use additional code” note unless documentation by the provider states that the conditions are unrelated. 

Now 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.

Initial, Subsequent, and Sequela 7th Character Assignment for Injuries, Poisonings, and Fractures

Explore the distinction between initial, subsequent, and sequela 7th character assignment for injuries, poisonings, and fractures in this episode of “In the kNOW.”  The usage of these 7th characters is intended to illustrate the care received for a particular patient encounter.  Let’s look at the meaning of each of these terms to help develop a better understanding of their application.

The 7th character used for initial care is “A” for active care which is explained as:

• Emergency room care 
• Surgical care  
• Evaluation/treatment by same/different physician

It is important to remember that not all surgical care will be active treatment however.  Consider a patient who had a Colles fracture with ORIF and now has a nonunion.  The internal fixation device must be removed so that is a procedure that will be performed after the patient had the active (initial) surgery for the repair and will not carry the “A” designation.  

Additionally, not every physician visit will be active care, even it is the first time a physician sees a patient.  For example, a boy had an ankle fracture and received surgical treatment.  Now, his family has moved to a new city and he has to see a new orthopedist in follow-up. That visit will be of a subsequent nature and carry the appropriate 7th character to reflect that status.

Active care may also be staged or necessitate multiple visits/physicians.

“D” is the 7th character used to show subsequent care for routine healing and recovery.  This can be used in a variety of circumstances such as:

• X-rays to monitor fracture healing
• Cast change/removal
• Internal/external fixation device removal
• Adjustment of medication
• Other types of aftercare or follow up visits

The 7th character for sequela is “S”.  A sequela is a condition/complication that is a direct result of another condition.  Think scar as a result of a burn.  The scar is the sequela.  An important note for sequelae is that there is no time table for a sequela.  It can be evident immediately after an injury or condition like dysphagia following a stroke, or it can take years to manifest such as the development of pleural calcifications years after TB.

The number of 7th characters expands when we talk about fractures.  Here the 7th character will tell if the fracture is:

• Closed/open  (A, B)
• Routine/delayed healing  (D, G)
• Nonunion/malunion  (K, P)
• Sequela  (S)

We’ll find another layer of specificity for those fractures that are designated with the Gustilo classification; open fractures of the forearm, femur, and lower leg.  These 7th characters take into consideration which type of Gustilo classification fits the fracture as outlined below:

• B=initial, open, type I or II
• C=initial open, type IIIA, IIIB, or IIIC
• E=subsequent, open, type I or II routine healing
• F=subsequent, open, type IIIA, IIIB, or IIIC routine healing
• H=subsequent, open, type I or II delayed healing
• J=subsequent, open, type IIIA,IIIB, or IIIC delayed healing
• M=subsequent, open, type I or II nonunion
• N=subsequent, open, type IIIA, IIIB, or IIIC nonunion
• Q=subsequent, open, type I or II malunion
• R=subsequent, open, type IIIA, IIIB, or IIIC malunion

With one exception, aftercare codes should not be assigned when coding care related to injuries, poisonings, and fractures because the 7th characters that have been discussed above provide a more specific indication of the type of aftercare given.  The exception is when a joint prosthesis has been previously removed due to a complication and now, at the episode of care when the replacement prosthesis will be inserted, an aftercare code is appropriate (Z47.3X)-aftercare following explantation of joint prosthesis (staged procedure).   

A final thought, for complications, active treatment relates to the treatment directed to the condition described by the code, not the problem that caused the condition which may have occurred earlier.  For instance, if a patient had a hip fracture and had to have a joint prosthesis which became infected, the code would be for the complication of the joint prosthesis which is infected, not the hip fracture which no longer exists but caused the need for the joint prosthesis. 

Now 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.

Epidural Steroid Injection (ESI) Codes

This installment of “In the kNOW” focuses on the changes to epidural steroid injection (ESI) codes.  Previous codes that identified ESIs have been deleted (62310, 62311, 62318, and 62319) and have been replaced with new codes ranging from 62320-62327. 

ESIs are a common, minimally invasive, treatment method for addressing pain that is the result of inflammation of spinal nerves.  Causes of the pain can be the herniation of an intervertebral disc, spinal stenosis or spondylolysis.  Two medications work in tandem when an ESI is administered.  The first component is a local anesthetic which will work to provide immediate symptom (pain) relief while the second is a corticosteroid which works to reduce the inflammation over time thus affording longer pain relief.  

Until the 2017 CPT update, ESI coding was based on:

the injection site: cervical/thoracic or lumbar/sacral,
            and
the method of administration: injection or injection with indwelling catheter.   

The new 2017 CPT codes for ESIs now include whether or not the ESI was administered with imaging guidance.
–    62320 injection C or T without Imaging Guidance
–    62321 injection C or T with Imaging Guidance
–    62322 injection L or S without Imaging Guidance
–    62323 injection L or S with Imaging Guidance
–    62324 injection with catheter C or T without Imaging Guidance
–    62325 injection with catheter C or T with Imaging Guidance
–    62326 injection with catheter L or S without Imaging Guidance
–    62327 injection with catheter L or S with Imaging Guidance

As coders begin the process of coding for ESIs now, the first consideration will be to determine where the needle or catheter enters the body.  Coders should note that the threading of the catheter into the epidural space, the injection of one or more levels, and the subsequent catheter removal are all components of a single injection.  The ESI should be considered a single injection even if the administered agent spreads to another level or the catheter tip moves into another region.  

When a catheter is placed for an ESI and is used on a single calendar day, coders should report ONE injection only, even if more than one injection is given.  Catheters that are left in place for more than one day in order to provide a bolus or continuous treatment will be coded to the new codes 62324-62327.

Now 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.

CPT Code Changes for 2017

This “In the kNOW” topic addresses a major change in CPT coding for 2017 regarding moderate (conscious) sedation.  This type of sedation allows a patient to purposefully respond when given verbal commands after being medicated.  It is not necessary to provide airway or cardiovascular support, and the patient’s own breathing is sufficient.  In the past, moderate sedation was considered part of select CPT codes and identified by the presence of an encircled bullet symbol, like this:

Effective January 1, 2017, there is a new way to code for moderate sedation thus resulting in revisions to many codes.  
 

A review of Appendix B indicates a large number of codes impacted by this change which is also reflected by review of Appendix G which has been removed from CPT.  Review of the explanatory note found under Appendix G provides coders with the information that the moderate sedation symbol, has been removed from the codes it was previously associated with and that is confirmed in Appendix B, where we see the codes preceded by the moderate sedation symbol with a strikethrough, like this: 

Appendix G now refers coders to new CPT codes 99151-99157 in order to capture moderate sedation, and Appendix B indicates that codes 99143-99150 which applied to procedures where it was appropriate to code moderate sedation separately have been deleted.  These new moderate sedation codes are inclusive of preservice, intraservice, and postservice work.  However, the code selection is solely based on the intraservice time as the pre and post work are included in the codes.  Components of the intraservice time include:

• Starts with administration of sedation
• Ends with completion of procedure, determination that patient is stable, and provider face-to-face time concludes
• Initial and subsequent orders and administration of sedation are included
• Continuous face-to-face time by provider is required
• Patient is monitored for sedation response

The new section of moderate sedation codes (99151-99157) are based on 15 minute increments of time as well as the age of the patient, and whether or not the sedation is provided by the same individual who is performing the diagnostic or therapeutic service.  For example, code 99151 is for the first 15 minutes of conscious sedation on a patient who is younger than 5 years old by the same provider performing the diagnostic or therapeutic service.  Add-on codes 99153 and 99157 are for each additional 15 minutes of intraservice time regardless of age.    

Further information on this important change in CPT can be found in the 2017 CPT Manual under Appendices B and G, and in the notes preceding the new CPT codes 99151-99157.  

Now you are In the kNOW!!

If you are interested in learning more about the CPT code updates coming in 2017, register for our webinar on this topic!  

Dianna Foley, the author of this article, will be the presenter on the webinar.  

 See our website for registration and details.

 
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.