Pneumonia is a medical condition that can vary from mild to life-threatening depending on age of the patient, especially in adults ages 65 and older and children younger than 2, overall health of the patient, and the cause/type of pneumonia. Many cases of pneumonia are treated successfully, but in serious cases, pneumonia can lead to complications and even death. Some complications associated with pneumonia are acute respiratory failure, ARDS (acute respiratory distress syndrome, sepsis, and lung abscesses. Treatment depends on the etiology of the patient’s pneumonia, and involves utilizing the correct antibiotic, anti-viral or anti-fungal, fluids, oxygen therapy and medicines to control pain, cough, and fever.
The type of pneumonia and any complications that develop can increase resource utilization and costs incurred by the hospital or facility by lengthening the patient’s stay, requiring use of oxygen or ventilation devices, and the medications given.
Ensuring complete and accurate code assignment is essential to covering the costs incurred from treating pneumonia. Failure to clarify the type of pneumonia may mean the incorrect DRG is assigned and does not reflect the patient’s severity of illness and resources required for treatment of the patient.
Recognizing opportunities to query for pneumonia requires understanding the types of pneumonia, their complications, if any, and the organism(s) causing the infection.
Many types of infectious organisms can cause pneumonia. Certain organisms are more common culprits depending on whether pneumonia was contracted in the community or is healthcare related.
This table lists some organisms that may cause pneumonia.
| Pneumonia Type | Organism |
| Gram-Positive | Streptococcus pneumoniae, Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis, Staphylococcus lugdunensis, Actinomyces isrealii, anaerobic |
| Gram- Negative | E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Acinetobacter baumannii, Legionella pneumophilia, Serratia marcescens, Chlamydophila pneumoniae, Achromobacter xylosoxidans, mycoplasma, anaerobic, Proteus mirabilis |
| Fungal | Histoplasmosis, coccidioidomycosis, Blastomycosis, Aspergillus, Candida, Cryptococcus, Pneumocystis |
There are many conditions and circumstances that make a patient more vulnerable to developing aspiration pneumonia, including:
Pneumonia is generally diagnosed by performing certain lab and radiological diagnostic testing.
The primary treatment of pneumonia is administration of antibiotics for bacterial pneumonia or antivirals for viral pneumonia. Below is a list of antibiotics and antivirals commonly used in the treatment of pneumonia.
Pneumonia cases can be complex. In some cases, patients with pneumonia may not have elevated WBCs if they are already on an antibiotic or the patient’s chest x-ray may be negative, but the patient clinical picture points to pneumonia according to other diagnostic findings. A positive sputum culture alone cannot be used to determine whether the patient is being treated for a specific type of pneumonia. Without the provider’s confirmation of the type of pneumonia being treated, a query would be necessary for accurate code assignment. When coding encounters for pneumonia, be on the lookout for multiple types of pneumonia and corresponding treatments. A patient can have both viral and bacterial or aspiration and bacterial pneumonia, etc.
ICD-10-CM Official Guidelines for Coding and Reporting provide direction when coding for pneumonia due to other conditions.
A query for the type of pneumonia and the organism involved is appropriate when the treatment involves antibiotics likely used for gram-negative organisms or organisms with antibiotic resistance.
A query is also appropriate when the patient has a pre-disposing condition, clinical syndrome or diagnosis that could lead to aspiration of fluids such as dysphagia, vomiting, or impaired swallowing etc.
References
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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.