Full Answer
Pneumonia, unspecified organism. J18.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2018/2019 edition of ICD-10-CM J18.9 became effective on October 1, 2018. This is the American ICD-10-CM version of J18.9 - other international versions of ICD-10 J18.9 may differ.
For instance, if severe sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician. “Multi-organ dysfunction” is not coded.
Coding tips: In ICD-10-CM, only one code is needed to report sepsis without organ dysfunction. Most sepsis codes can be found in A40.- through A41.9.
Example: A patient is admitted with pneumonia and acute hypoxic respiratory failure. On day four, the patient worsens and becomes hypotensive and is diagnosed with sepsis, septic shock, and acute renal failure. On the discharge summary, pneumonia is documented as the principal diagnosis.
Symptoms include cough, shortness of breath, fevers, chills, chest pain, headache, sweating, and weakness. Inflammation of any part, segment or lobe, of the lung parenchyma. Inflammation of the lungs with consolidation and exudation. Pneumonia is an inflammation of the lung, usually caused by an infection.
You can also get pneumonia by accidentally inhaling a liquid or chemical. People most at risk are older than 65 or younger than 2 years of age, or already have health problems. If you have pneumonia, you may have difficulty breathing and have a cough and a fever. A physical exam and history can help determine if you have pneumonia. Chest x-rays and blood tests can help determine what is wrong. Treatment depends on what made you sick. If bacteria are the cause, antibiotics should help. Viral pneumonia may get better with rest and drinking liquids.preventing pneumonia is always better than treating it. The best preventive measures include washing your hands frequently, not smoking, and wearing a mask when cleaning dusty or moldy areas. There is a vaccine for pneumococcal pneumonia, a bacterial infection which accounts for up to a quarter of all pneumonias.
pneumonia due to solids and liquids ( J69.-) aspiration pneumonia due to solids and liquids ( J69.-) neonatal aspiration pneumonia ( P24.-) (noo-mone-ya) an inflammatory infection that occurs in the lung. A disorder characterized by inflammation focally or diffusely affecting the lung parenchyma.
The 2022 edition of ICD-10-CM J18.9 became effective on October 1, 2021.
This may cause a decrease in the amount of oxygen that blood can absorb from air breathed into the lung. Pneumonia is usually caused by infection but may also be caused by radiation therapy, allergy, or irritation of lung tissue by inhaled substances. It may involve part or all of the lungs.
Nursing home as the place of occurrence of the external cause 1 Y92.12 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. 2 Short description: Nursing home as place 3 The 2021 edition of ICD-10-CM Y92.12 became effective on October 1, 2020. 4 This is the American ICD-10-CM version of Y92.12 - other international versions of ICD-10 Y92.12 may differ.
The 2022 edition of ICD-10-CM Y92.12 became effective on October 1, 2021.
Y92.12 describes the circumstance causing an injury, not the nature of the injury. This chapter permits the classification of environmental events and circumstances as the cause of injury, and other adverse effects. Where a code from this section is applicable, it is intended that it shall be used secondary to a code from another chapter ...
Nursing home as the place of occurrence of the external cause. 2016 2017 2018 2019 2020 2021 Non-Billable/Non-Specific Code. Y92.12 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. Short description: Nursing home as place.
Aspiration of fluid as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure 1 Y84.4 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 Short description: Aspiration of fluid cause abn react/compl, w/o misadvnt 3 The 2021 edition of ICD-10-CM Y84.4 became effective on October 1, 2020. 4 This is the American ICD-10-CM version of Y84.4 - other international versions of ICD-10 Y84.4 may differ.
The 2022 edition of ICD-10-CM Y84.4 became effective on October 1, 2021.
Y84.4 describes the circumstance causing an injury, not the nature of the injury.
An elderly nursing home patient was admitted for pneumonia. He has frequent aspiration because of difficulty swallowing due to a previous stroke. This pneumonia was documented as aspiration pneumonia. He was also found on admission to have stage 2 decubitus ulcer on the left buttock. The patient received skin care by the nursing staff for this ulcer. What codes are assigned in this case?
Rationale: For code M05.59, the Alphabetic Index main term is Neuropathy, subterm peripheral (nerve) (see also Polyneuropathy); Polyneuropathy, in (due to), rheumatoid arthritis—see Rheumatoid, polyneuropathy; Rheumatoid, polyneuropathy, multiple sites.
For code J69.0, the Alphabetic Index main term is Pneumonia, subterm aspiration.
Rationale: The Alphabetic Index main term is Dementia with subterm vascular. In the Tabular list, there is a note to use additional code to identify wandering under the code selection for Vascular dementia with behavioral disturbance. Wandering is considered a "behavioral disturbance," so the correct code assignment for the dementia is F01.51. The additional code for wandering is also assigned per the instruction note. Diseases of the Nervous System, Eye and Adnexa, and Ear and Mastoid Process
The POA indicator is Y, as the condition was present on admission.
For code T45.1X5A, the Alphabetic Index main term is Azathioprine, subterm adverse effect.
If the patient has severe sepsis, add R65.2- with the codes for specific organ dysfunctions.
A41.51 Sepsis due to Escherichia coli [E. coli] N39.0. SIR S. SIRS is the body’s clinical cascading response to infection or trauma that triggers an acute inflammatory reaction and progresses to coagulation of the blood, impaired fibrinolysis, and organ failure.
The discharge diagnoses were influenza with pneumonia bacterial superinfection, positive for pseudomonas, as well as acidosis, asthma exacerbation, hypoxemia, and chronic bronchitis. Sepsis and SIRS were not mentioned on the discharge summary, and are mentioned only sporadically throughout the progress notes.
For instance, if severe sepsis, pneumonia, and acute renal failure due to dehydration are documented, the code for severe sepsis may not be assigned because the acute renal failure is not stated as due to or associated with sepsis. If the documentation is unclear, query the physician.
Documentation issues: You can code for sepsis when the physician documents the term “sepsis.”. Documentation should be consistent throughout the chart. Occasionally, during an extended length of stay, sepsis may resolve quickly and the discharging doctor may not include the diagnosis of sepsis on the discharge summary.