Pneumonia ranks sixth in frequency of diagnoses processed by the McKesson Emergency Medicine Services division.

Patients who visit the emergency department for medical symptoms such as coughing, shortness of breath or difficulty breathing, low or mild fever, enlarged lymph nodes, sore throat, sharp chest pain, or dark or bluish fingernails or toenails may be evaluated for a respiratory/lung problem.

Emergency medicine providers may consider pneumonia one of the differential diagnoses, which would be considered a working diagnosis. If the provider’s cognitive thought process leads them to the path of pneumonia, they will also consider the type of pneumonia which may be present – viral, bacterial, infectious or a mycoplasma type of pneumonia.

If pneumonia is suspected, specific measures may be taken. A chest X-ray may be ordered, CBC blood tests may be drawn to check the white blood count, arterial blood gasses may be used to check if enough oxygen is getting into the blood from the lungs, and other specific tests may be performed. A CAT scan will be used to determine how the lungs are functioning; sputum tests will used to look for the organism (that can be detected by studying the saliva); and other tests may identify potential fluid in the space around the lungs. Additionally, a pulse Oximetry will be used to measure the oxygen moving through the bloodstream and possibly a bronchoscopy if the condition continues to worsen.

To date, many emergency department charts have shown final diagnosis documentation that states “typically after study, pneumonia,” without any elaboration of the type of pneumonia. In ICD-9 the code is “486 – Pneumonia, organism unspecified” and it approximately converts to ICD-10 code “J18.9 – Pneumonia, unspecified organism”. This type of medical condition, with the varied number of pneumonia types, requires the provider to include more detail to the final diagnosis based on the findings after study. As stated above there are many types of pneumonia.

There is a one-to-one crosswalk for pneumonia, organism unspecified.

ATC Pneumonia Code 1

Treatment for pneumonia depends on the type of pneumonia and how severe it is. The goals of treatment are to cure the infection and prevent complications. The entire work-up and treatment plan prepared for the patient is the provider’s responsibility. However, for that provider to get the greatest level of specificity in the final diagnosis under the ICD-10 world, more detailed documentation is required in that final statement of diagnosis for proper billing. This requirement also applies to the coding – in order for the coding staff to assign the appropriate ICD-10 code to its greatest level of specificity, it is important for the provider to document the detailed findings of study in the final impression or diagnosis. When a provider documents a final diagnosis that is not to its greatest level of detail, an unspecified code is typically assigned.

Pneumonia codes in ICD-9 are in the code range 480 – 488 under “Pneumonia and Influenza.” The ICD-10 section for Pneumonia is J09 – J18 under Influenza and Pneumonia. Note that this is not a typo but the way it is listed in the code books. The description has been reversed – as was similar to the description for the ICD-9 and ICD-10 codes for pneumonia unspecified. The beginning of the ICD-9 and ICD-10 pneumonia sections has a note which shows codes that are excluded from this family of codes. Some of the excluded codes are other types of pneumonia (i.e., allergic, aspiration and rheumatic – all pneumonia). These are good examples of why the greater level of detail is so important in order to assign the most appropriate ICD-10 code.

Some examples of crosswalks from ICD-9 to ICD-10 for pneumonia are outlined below. 

ATC Pneumonia Code 2

As shown in the table above, there are a number of ICD-10 codes for pneumonia. This is only a small example of those codes in both ICD-9 and ICD-10 books. It is imperative that the provider document exactly what the diagnostic study’s findings are, if any, to determine the exact course of action for the condition presented or defined after study in order to establish the appropriate code.

This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of emergency medicine and emergency medical

services. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.

Author - Male

About the author

Robert Bunting, CPC, CPC-H, CHC, CEDC, CEMC, CAC is Compliance Director – Emergency Medicine, McKesson Business Performance Services.