Aspiration Pneumonia: Clinical Documentation and ICD-10-CM

A healthcare professional analyzing lung screenings for aspiration pneumonia on a computer monitor

The respiratory system oversees the gas exchanges that occur between the blood, tissue cells and the lungs. There are times when an individual will develop an infection or inflammation of the lung(s) called “Pneumonia” and treatment is needed. Most of the time pneumonia is caused from a virus, bacteria, fungi, or parasites. In addition, pneumonia can be caused by aspiration of fluids, solids/foods, vomitus, stomach contents and/or saliva. For Medical Coding and Clinical Documentation Integrity (CDI) professionals understanding the clinical, accurate documentation and ICD-10-CM coding for pneumonia is vital, especially for cases with a diagnosis of “Aspiration Pneumonia”.  With the increase in payer denials and external regulatory compliance reviews, awareness of some key clinical and coding aspects can always help.

Have you ever heard this from someone who appears to choke or cough briefly when eating, drinking, or swallowing, “It went down the wrong way”? Maybe you’ve had that happen to yourself. Something has gone down the airway into the lungs, instead of the esophagus. The human reflex gag starts immediately to try remove what is not air from the airway and/or lungs with coughing. Although this can be a single short episode of aspiration, it can result in a pneumonia and may even lead to the diagnosis of aspiration pneumonia. A lung infection and/or inflammation can occur, and medical attention is needed. The signs, symptoms, clinical indicators, and treatment of aspiration pneumonia all require complete documentation and accurate ICD-10-CM coding for a compliant patient encounter claim submission and data collection.

Lung Anatomy:

Looking more closely at the anatomy of the lung we find that in humans there are two lungs which are divided into multiple smaller sections by fissures. These sections are called the “lobes” of the lungs. The number of lobes varies between the right and left lungs in a normal human being. The right lung has three lobes, namely, the superior (upper), middle and inferior (lower) lobes unlike the right lung, there are only two lobes in the left lung: the superior (upper) and inferior (lower) lung lobes. The left lung is a little smaller than the right lung because it has to make space for the heart (the cardiac notch) in the left side of the thoracic cavity. As a result, the right lung is larger, having three lobes, while the left one only has two. Clinically, some types of pneumonia appear in a specific lobe more often, such as aspiration, which appears more often in the right lower lobe.

Common Signs & Symptoms:

There are a variety of signs and symptoms that an individual can have for Pneumonia, some of these will depend on the age of the person. The following list is not all inclusive:
  • Cough (productive and/or non-productive)
  • Shortness of Breath and/or Wheezing
  • Fever and/or Chills (some patients will have a lower-than-normal temperature)
  • Chest pain and Pleuritis
  • Fatigue
  • Nausea, Vomiting and/or Diarrhea

Aspiration pneumonia will also have the above signs and symptoms but there may be a patient history of dysphagia, swallowing difficulties/disorders, brain injury, poor gag reflex, presence of a NG tube, drug and/or alcohol use; any of these can contribute to aspiration, so read through the documentation completely. Bedridden patients (SNF or LTC) and those who need the head of the bed elevated is a clue that they be at risk for aspiration (review the MD orders and Nursing Notes). In addition, a patient who had a seizure or a seizure disorder has a higher incidence of aspiration pneumonia as well. Again, reviewing the clinical documentation for the above information will be extremely important for CDI and Coding staff.

Treatment:

There are several great websites which outline the most common treatments for pneumonia, they often include treatment for aspiration pneumonia:
  • Chest x-ray or CT scan – review imaging results/impression
  • Sputum Culture and Blood Culture – check the lab results for abnormal findings
  • CBC – check for an elevation in WBC’s – although not always present
  • Antibiotics – review which type of antibiotic is prescribed
  • Arterial Blood Gases (ABGs) – review the results
  • Respiratory Therapy Treatment
  • Dietary changes (soft and fluid food) – watch for details
  • Swallowing Evaluation – check for MD orders and results

It should be noted that with aspiration pneumonia, there can often be an associated bacterial pneumonia that can occur. Checking the documentation for details on a productive cough of yellow or green sputum which can be helpful in identification of the organism (bacteria) and a clinical indicator opportunity for a query. Also review the sputum cultures when performed for the results and what bacteria grew; this is another opportunity for clinical indicators.

Documentation:

Identifying the specific documentation on the type of pneumonia is the first step of completion. Next, look to see if aspiration pneumonia is documented as confirmed or suspected, then conduct a query if uncertain, and querying for the cause of the aspiration would be warranted as we don’t want to assume. Always reading over the emergency room documentation, history and physical, progress notes, MD orders, radiology, and labs. The nursing notes can also give you some information to help with determining when to query the provider. The discharge summary should also support the aspiration pneumonia diagnosis for accurate coding and reporting of the ICD-10-CM code. We are seeing across the healthcare industry that payers require the diagnosis documentation to appear in more than one location in the health record, so be sure that you consider this when querying the provider.

ICD-10-CM:

The “Pneumonia” diagnosis is found in Chapter 10 Diseases of the Respiratory System J00-J99, and at the J60-J70 Lung disease due to external causes range. Then at J69 within the tabular Pneumonitis due to solids and liquids, you will see the following choices for aspiration pneumonia, note the excludes notes and the inclusion terminology (conditions) for each code in this range.

Excludes1: neonatal aspiration syndromes (P24.-)
postprocedural pneumonitis (J95.4)
J69.0 Pneumonitis due to inhalation of food and vomit

Aspiration pneumonia NOS
Aspiration pneumonia (due to) food (regurgitated)
Aspiration pneumonia (due to) gastric secretions
Aspiration pneumonia (due to) milk
Aspiration pneumonia (due to) vomit
Code also any associated foreign body in respiratory tract (T17.-)
Excludes1: chemical pneumonitis due to anesthesia (J95.4)
obstetric aspiration pneumonitis (O74.0)

J69.1 Pneumonitis due to inhalation of oils and essences

Lipoid pneumonia
Lipid pneumonia NOS
Code first (T51-T65) to identify substance
Excludes1: endogenous lipoid pneumonia (J84.89)

J69.8 Pneumonitis due to inhalation of other solids and liquids

Pneumonitis due to aspiration of blood
Pneumonitis due to aspiration of detergent
Code first (T51-T65) to identify substance

As one can see from the above tabular listing, there is more than one aspiration pneumonia/ pneumonitis ICD-10-CM code to select based upon the substance aspirated. Documentation needs to be specific, and a query may be needed to confirm the specific substance that was aspirated. Data shows that J69.0 is the most frequent ICD-10-CM code reported within the aspiration pneumonia subcategories. It might be prudent to run a report of the code range J69 and see what your most frequent code is as well as a general data run for your top ICD-10-CM Pneumonia code assigned overall.

Track and trend all your denials, especially for the diagnosis of pneumonia, try to capture if a query was utilized or not as well. Provider education may be an option to help with documentation specificity and with all pneumonia diagnoses to ensure the specific type is documented if known. Review your healthcare facility and practice clinical and coding denials carefully and then review the specific health record for the encounter in question. Yes, the health record documentation can at times be conflicting (initiate a query) and even challenging. Carefully read the documentation for the circumstances of admission. Remember the UHDDS definition of a principal diagnosis is designated and defined as: the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

There are many good websites (Mayo Clinic, Cleveland Clinic, CDC) and articles on aspiration pneumonia that one should review. In addition, Pinson and Tang CDI Pocket Guide has good information on Pneumonia for the CDI and Medical Coding professional. Enhancing one’s knowledge and at times reviewing one’s knowledge regarding the clinical aspects of a condition or disease (diagnosis) brings great value to the coding and CDI processes. Ultimately, we can identify opportunities to improve the capture of patient severity and acuity which reflects the true patient story for the encounter and achieve healthcare medical coding compliance.

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