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Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines

JustCoding News: Inpatient, December 7, 2011

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As the weather cools, the heat is on coders to properly report the high number of pneumonia cases they tend to see during the winter months.

It's not always easy, considering the changing face of pneumonia testing and treatment and the number of documentation requirements for coding. In particular, cases "without a smoking gun," such as pneumonia without a positive chest x-ray, can be particularly challenging for clinician and coder alike, said Lolita M. Jones, RHIA, CCS, sole principal of Lolita M. Jones Consulting Services in Fort Washington, MD. Jones spoke along with Joy J. King, RHIA, CCS, CCDS, principal of Joy King Consulting, LLC, in Birmingham, AL, during HCPro's September 8 audio conference, "Top ICD-9-CM Trouble Spots: Master Clinical Background and Coding Guidelines for Accurate Coding."

However, a solid understanding of both the clinical aspects and the guidelines for pneumonia coding can help coders correctly report pneumonia during the long winter months and beyond.

Diagnosing pneumonia

"Research is showing that we shouldn't be surprised to see more and more clinical diagnoses in the absence of positive chest x-rays," Jones said. There are a number of reasons why.

For example, Jones noted that even when looking at the same x-rays, radiologists couldn't always agree whether an infiltrate was present, according to an article by Edward Doyle in the February 2006 issue of Today's Hospitalist. Doyle also found that CT scans may actually be a better tool for diagnosing clinical pneumonia.

"A chest x-ray is probably still the first line of defense, the first thing a physician orders to figure out if [pneumonia] is present, but we may be getting to a point when a CT scan of the chest may soon become the prevailing test," Jones said.

That said, the chest x-ray for infiltrates may remain the go-to diagnosis tool simply because of a number of quality care initiatives that require physicians to treat pneumonia patients within a certain number of hours after admission.

Those initiatives "are looking for the physicians to say, for example, ‘I treated this particular condition because I found infiltrates on the x-ray so I know I'm treating pneumonia,' " Jones said, explaining that a physician knowing in his or her gut that a patient has pneumonia regardless of a negative chest x-ray doesn't always cut it with external review organizations. "Unfortunately, the quality guidelines and parameters out there haven't caught up with the fact that there are a number of conditions out there that can be treated based on signs and symptoms even if diagnostic tests are negative, and pneumonia is one of them."

Another challenge for pneumonia diagnoses is the rise of drug-resistant organisms. Prescribed antibiotics may not work the first or even second time. Drug resistance was fairly uncommon in the past, according to Jones, but that's no longer the case.

"We need to be sensitive to the fact that you can't say it wasn't pneumonia because the first round of antibiotics didn't work ... the patients may have a clinical pneumonia that is due to a bacteria or virus, for which the patient is drug-resistant," she said.

As the medical industry adapts, coders may see other alternative testing methods documented more frequently in the record. For example, physicians may order C-reactive protein (CRP) tests to test for bacterial pneumonia.

This is a finger stick test that measures the patient's level of CRP, which is stimulated by bacteria and rises in the presence of an infection. A very high level can indicate pneumonia, according to Doyle.

Similarly, physicians can test for rising procalcitonin levels or S-TREM (soluble triggering receptor expressed on myeloid cells), Jones said.

"[Instead of] the tests that we're used to seeing and the treatment protocols that we're used to seeing, I think we really are moving into the next generation. And what we've become used to seeing in the past—what a lot of our queries have been based around, along with tests, documentation training, in-services with physicians—a lot of it needs to begin to move forward according to what's really being seen out there," Jones said. "So much of it is changing. We have to look at what is going on right now and how the practice of medicine is changing."

Pneumonia coding guidelines

Despite the changing clinical preferences for diagnosing pneumonia, the positive chest x-ray is still considered the standard by recovery audit contractors (RAC), the Office of Inspector General, and other auditors, King said. As such, coders need to watch for it in documentation.

Coders should also look for indication that fluids were provided to the patient, particularly prior to a chest x-ray. If a patient presents with dehydration, he or she would usually need fluids before an infiltrate would show up on a chest x-ray regardless of the presence of pneumonia, King explained.

Without a positive chest x-ray, coders should look for other signs and symptoms documented in the record, she said. These could include a heart rate above 100 bpm or a respiratory rate above 25, rales, crackles, rhonchi, a dullness to percussion, or decreased breath sounds.

"Certainly, if you have a physician advisor or champion, or a [clinical documentation improvement] program, communication with the attending physicians about the importance of documenting more about their clinical diagnosis of pneumonia when they don't have that infiltrate is going to be increasingly important," King said.

Another issue coders should watch for is hypoxemia with pneumonia.

Unlike with respiratory failure, hypoxemia is not inherent to pneumonia. Per Coding Clinic, Second Quarter 2006, if a physician documents hypoxemia in the record, coders need to report it separately from the code for the pneumonia diagnosis, according to King.

Finally, there is the ongoing issue of assuming causal organisms based on sputum cultures. As discussed in Coding Clinic, Second Quarter 1998, coders simply cannot do it, King explained.

"Sputum cultures are often misleading or negative," she said. "The physician must actually document a link between the results on the culture and the pneumonia itself in order for coders to link them. This continues to be something that coders struggle with."

ICD-10 coding for pneumonia

Documentation requirements shouldn't change much with the switch to ICD-10-CM/PCS, according to Jones. "We still need a definitive diagnosis of pneumonia, or at the very least a statement on the discharge summary that the pneumonia was not ruled out so that we can know what we're dealing with from a coding standpoint."

The codes, however, will certainly change; there are numerous codes for pneumonia in the new system, including the following:

  • J18.0 (bronchopneumonia, unspecified organism)
  • J18.1 (lobar pneumonia, unspecified organism)
  • J18.2 (hypostatic pneumonia, unspecified organism)
  • J18.8 (other pneumonia, unspecified organism)
  • J18.9 (pneumonia, unspecified organism)

"This is just a sampling of the numerous codes out there for ICD-10," Jones explained. "There's a completely different batch of codes for when you have an organism specified."

In particular, coders may want to note ICD-10-CM code J18.9, which is essentially the replacement code for the ICD-9-CM code 486 (pneumonia, unspecified organism), she said.

Additional clinical pneumonia coding guidelines

Need more guidance on coding for clinical pneumonia? Coding Clinic may well have the answers you need; the topic has been addressed in the publication numerous times. King notes the following Coding Clinic issues

  • Fourth Quarter 2010, p. 135
  • First Quarter 2010, pp. 3, 12
  • Third Quarter 2009, p. 16
  • Fourth Quarter 2008, pp. 69, 140
  • Second Quarter 2006, pp. 20, 24
  • Second Quarter 2003, pp. 21–22
  • Fourth Quarter 1999, p. 6
  • Third Quarter 1998, p. 7
  • Second Quarter 1998, pp. 3–5, 7
  • First Quarter 1998, p. 8
  • Third Quarter 1997, p. 9
  • Fourth Quarter 1995, p. 52
  • Third Quarter 1994, p. 10
  • First Quarter 1994, pp. 17–18
  • Third Quarter 1993, p. 9
  • First Quarter 1993, p. 9
  • First Quarter 1992, pp. 17–18
  • First Quarter 1991, p. 13
  • Third Quarter 1988, pp. 11, 13
  • M-A 1985, p. 6

This list can be a very valuable tool as you develop guidelines for coding and querying for your coding staff, King says.

Editor’s note: This article was originally published in the November issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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