At a glance, you knew that this pleasantly demented 91-year-old woman from a nearby nursing home would need to be admitted. Your exam and x-ray confirmed the presence of right lower lobe pneumonia. The sputum Gram’s stain showed Gram-positive cocci in pairs. She has a fever, productive cough, and pleuritic chest pain. She desaturates without supplemental oxygen. Her blood pressure is borderline, and her pulse is 105 after a fluid bolus and acetaminophen. She has a leukocytosis with a left shift. Sodium is 131. Appropriate antibiotics are already infusing when you call the hospitalist for admission.

However, you are not just an astute clinician. You documented all seven of the components needed to facilitate correct coding of an infectious illness using ICD-10. 

• Type, location, and acuity: acute right lower lobe pneumonia
• Causative organism: Streptococcus pneumonia
• Complications: hypoxia, tachycardia
• Significant lab findings: hyponatremia, leukocytosis

Even better, you performed a comprehensive exam, and you documented the stage 3 pressure ulcer on her right hip. The hospital can now report this as a condition present on admission.

Furthermore, you recognized that the primary reason for admission or most serious illness/injury should be listed first.

Your diagnoses:

J13	Pneumonia due to Streptococcus pneumoniae
L89.213	Pressure ulcer of right hip, stage 3
E87.1	Hypo-osmolality and hyponatremia

 

For the Evaluation & Management service, the coder would also assign a CPT code such as 99285.

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page. 

08/2015