Pneumonia refers to an infection that causes inflammation in the lungs. Pneumonia can also occur as a result of less severe illnesses like the flu, if the infection hangs on without getting better. CNBC reported that following the increasing cases of measles in the U.S., some people are even developing severe complications such as pneumonia or brain swelling. Physicians providing treatment for such conditions can rely on medical coding companies to meet their reimbursement concerns. Symptoms of this condition includes chest pain while breathing or coughing, cough, often with phlegm, fatigue, fever, sweats and chills, nausea, loss of appetite, vomiting or diarrhea as well as shortness of breath. It can cause damage to the thin lining of the lungs.
Based on a pair of surveys, COPD Foundation published a research report in 2018, highlighting that Community-acquired Pneumonia (CAP) can have a significantly worse effect among patients with chronic obstructive pulmonary disease (COPD) than those without. At the same time, a study presented at ATS 2019 found that bacterial pneumonia is linked to ongoing lung problems in previously healthy infants, who were hospitalized in a pediatric intensive care unit for acute respiratory failure.
ICD-10 coding for the causes of pneumonia
Pneumonia is caused by a bacterial, viral or fungal infection. Different causes have to be documented in medical claims with different codes. In nursing facilities, the most common pneumonias encountered are bacterial, viral, or caused by aspiration or procedure complication (iatrogenic).
It is critical to assign the correct ICD-10 codes for the provider’s diagnosis.
To document this, medical coders should know the exact causative organism, such as Klebsiella, Pseudomonas, staphylococcus, staphylococcus, streptococci, and Escherichia coli.
Codes related to this infection is found in ICD-10 code category J15
- J15 Bacterial pneumonia, not elsewhere classified
- J15.0 Pneumonia due to Klebsiella pneumoniae
- J15.1 Pneumonia due to Pseudomonas
- J15.2 Pneumonia due to staphylococcus
- J15.3 Pneumonia due to streptococcus, group B
- J15.4 Pneumonia due to other streptococci
- J15.5 Pneumonia due to Escherichia coli
- J15.6 Pneumonia due to other Gram-negative bacteria
- J15.7 Pneumonia due to Mycoplasma pneumoniae
- J15.8 Pneumonia due to other specified bacteria
- J15.9 Unspecified bacterial pneumonia
While choosing a bacterial pneumonia code, it is crucial for coders to remember that according to the guidelines from CMS, if the resident happens to have associated viral influenza as well, it should be reported with codes such as
- J09.X1 Influenza due to identified novel influenza A virus with pneumonia
- J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia or
- J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia
Viral causes of this respiratory condition can be SARS, syncytial virus or influenza. Categories J10 and J11 have codes for influenza with associated pneumonia.
- J10 Influenza due to other identified influenza virus
- J10.0 Influenza due to other identified influenza virus with pneumonia
- J10.1 Influenza due to other identified influenza virus with other respiratory manifestations
- J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations
- J11 Influenza due to unidentified influenza virus
- J11.0 Influenza due to unidentified influenza virus with pneumonia
- J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations
- J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations
- J11.8 Influenza due to unidentified influenza virus with other manifestations
If the provider documents the presence of novel influenza A virus and parainfluenza virus, use the specific code “J12.2 Parainfluenza virus pneumonia”. But, the first code should be “J09.X1 Influenza due to identified novel influenza A virus with pneumonia” to report the influenza A virus.
This is a complication of pulmonary aspiration, when any one inhales food, stomach acid, or saliva into their lungs. This can be coded under J69 category.
- J69 Pneumonitis due to solids and liquids
- J69.0 Pneumonitis due to inhalation of food and vomit
- J69.1 Pneumonitis due to inhalation of oils and essences
- J69.8 Pneumonitis due to inhalation of other solids and liquids
For instance, if the physician documents the presence food particles in the trachea, and the condition as aspiration pneumonia, coders might use J69.0 code, as it covers aspiration pneumonia due to food regurgitation, gastric secretions, and vomiting. However, it is also recommended to use code from category T17 to refer to an associated foreign body in respiratory tract.
Also referred to as nosocomial pneumonia or hospital-acquired pneumonia (HAP) this condition is the result of the complication of any medical procedure in a hospital at least 48–72 hours after being admitted. To document this, coders must be familiar with coding for hospital-acquired conditions (HAC).
For example, if the documentation indicates pneumonia during treatment while on a ventilator, use the code “J95.851 Ventilator associated pneumonia”. Additional codes that can be used to identify the organism includes
- B95 Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere
- B96 Other bacterial agents as the cause of diseases classified elsewhere and
- B97 Viral agents as the cause of diseases classified elsewhere
Additional diagnosis codes for sepsis (R65.2-) or respiratory failure (J96.-) can be used in case of any additional documentation.
There are also possibilities for pneumonia to occur due to other causative organisms such as fungus, parasite, or mycosis. For pneumonia conditions that aren’t bacterial, viral, or due to aspiration, use codes such as
- A22.1 Pulmonary anthrax
- A43.0 Pulmonary nocardiosis
- B37.1 Pulmonary candidiasis
- B58.3 Pulmonary toxoplasmosis
- B59 Pneumocystosis
- B05.2 Measles complicated by pneumonia
Pulmonary medical coding services provided by AAPC-certified coders can help doctors in this specialty optimize reimbursement for the services they offer. Make sure that the coders are well-versed in the codes relating to the diagnosis and treatment of diseases affecting the lungs and respiratory tract.