Health Information Management

Q&A: Coding 'aspiration without pneumonia'

HIM-HIPAA Insider, June 28, 2011

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Q: Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said that the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia, he said the patient doesn’t have pneumonia. He said the patient also doesn’t have a foreign body. What should I do?

A: It is difficult to answer without more information. Mendelson’s syndrome is a bronchitis or pneumonitis resulting from macroaspiration of acidic stomach contents usually associated with endotracheal intubation.
 
When patients have this condition, coders should report ICD-9-CM code 997.39 (other respiratory complications) plus a code for the pulmonary condition. Aspiration pneumonia and aspiration bronchitis both map to the same ICD-9-CM code, 507.0 (pneumonitis due to inhalation of food or vomitus).
 
Because ICD is an international classification system maintained by the World Health Organization, it tends to group similar conditions under the same code. This is unlike CPT®, with which physicians may be more familiar. The AMA maintains CPT, which includes more procedure- and encounter-specific codes. In this case, the physician must provide clarification so a coder can report the most accurate ICD-9-CM code.
 
Editor’s note: William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, answered this question in the June issue of Briefings on Coding Compliance Strategies.



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