Medical Coding for Lobar Pneumonia and Bronchopneumonia

Question: What is lobar pneumonia? Is right lower lobe (RLL) pneumonia coded as lobular pneumonia?

Pneumonia is a common infection that affects the air sacs in one or both lungs. Unfortunately, when the air sacs fill with pus and other liquid, the infection can become quite serious and even fatal. The role of the coder is to review the provider’s documentation for the specific type of pneumonia and the causative organism, if stated, and assign the appropriate diagnosis code.

According to the National Institutes of Health:

The annual incidence of community-acquired pneumonia (CAP) is approximately 516 to 611 cases per 100,000 persons in adults, and the rate increases with age.
In the United States, approximately 5.6 million cases of CAP are reported annually. Among them, 2% to 24% require admission to an intensive care unit (ICU), and 2% to 3% lead to death.

Pneumonia Classifications

Pneumonia is classified based on the types of germs that cause it and where the infection was acquired. Common types of pneumonia include community-acquired pneumonia (CAP), healthcare-associated (HCAP), hospital-acquired (HAP), and aspiration pneumonia (AP).

Community-acquired pneumonia (CAP)

This is the most common type of pneumonia and occurs outside of hospitals and other healthcare facilities. It may be caused by:

Bacteria – Most common cause of bacterial pneumonia in the U.S. is Streptococcus pneumoniae.
Bacteria-like organisms – Mycoplasma pneumoniae can be the cause and is usually milder than other types of pneumonia. It is often called walking pneumonia and does not usually require bed rest.
Fungi – Most common in people with weakened immune systems, chronic health problems, or in those who have inhaled large amounts of the organisms. The fungi that cause it varies based on geographic location and can be found in soil or bird droppings.
Viruses – Ranging from mild to serious, viruses are the most common cause of pneumonia in children under 5. Some of the viruses that cause colds and flu can also cause pneumonia.

Hospital-acquired pneumonia (HAP)

People who are being treated in the hospital for another condition may catch pneumonia. HAP can be severe, because the bacteria that causes it may be more resistant to antibiotics, or because the people who get it are already ill. Those at higher risk for this type of pneumonia use breathing machines and are in intensive care units.

Healthcare-acquired pneumonia (HCAP)

People who live in long-term care facilities or who receive outpatient care, such as in kidney dialysis centers, may catch HCAP. HCAP is similar to HAP in that it is caused by bacteria that are more resistant to antibiotics.

Aspiration pneumonia (AP)

This type can occur when a person inhales food, drink, saliva, or vomit into the lungs. A person with a brain injury, swallowing problem, or excessive user of alcohol or drugs is more likely to acquire AP.

Specific Types of Pneumonia

The two main types of acute bacterial pneumonia are lobar pneumonia and bronchopneumonia, also known as lobular pneumonia.

Lobar Pneumonia

Lobar pneumonia is a lung infection that affects a large part of a lung lobe or the entire lobe. When more than one lobe is affected, it is referred to as multilobar. When all lung lobes are affected, it is referred to as panlobar pneumonia.

The cause of lobar pneumonia is usually bacteria, such as Streptococcus pneumoniae or Haemophilus influenzae. Other bacterial causes include Klebsiella, Mycoplasma, or Legionella. A virus can also cause lobar pneumonia.

Four stages of lobar pneumonia:

Congestion in the first 24 to 48 hours with distention of the blood vessels of the lung, and fluid in the air sacs (alveoli)
Red hepatization or consolidation on the second to fourth day with fluid, red cells, white cells (neutrophils), and fibrin in the air sacs. Looking under a microscope, the lung tissue looks like liver tissue
Grey hepatization on the fourth to sixth day with breakdown of red liver cells and persistence of neutrophils and fibrin in the air sacs
Resolution on the eighth to ninth day with a complete recovery

Symptoms of lobar pneumonia often come on abruptly and may include coughing up yellow, green or rusty mucus, higher fever, shortness of breath, fatigue, and chest pain upon coughing.

When the physician taps on the chest (percussion), a dull sound can be heard. When listening to the lungs with a stethoscope (auscultation), the physician can hear crackling sounds and sounds of decreased breathing over the affected lung lobe.

On an X-ray, lobar pneumonia presents as a single unbroken white patch in a lung lobe, or two or more patches if more lobes are affected.

Treatment is based on the cause. If it is bacterial pneumonia, antibiotics will be used. If it is viral pneumonia, anti-virals will be the treatment.

Bronchopneumonia

Bronchopneumonia, also referred to as bronchial pneumonia, multifocal, or lobular pneumonia, is an acute inflammation of the small airways within the lungs (bronchioles) and the surrounding lung tissue (alveoli).

The cause of bronchopneumonia, like lobar pneumonia, is usually bacterial. The bacteria may be Staphylococcus aureus, Klebsiella pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, or Escherichia coli. Bronchopneumonia usually occurs in hospital patients (hospital-acquired) and patients requiring a breathing machine. It also occurs in a person who aspirates vomit and in intravenous drug abusers. Other causes of bronchopneumonia include atypical bacterium Mycoplasma, fungi, and viruses.

Bronchopneumonia is not contagious when a person with the condition comes in close contact with someone else. However, the microbes that cause bronchopneumonia can be contagious when the infected person sneezes or coughs and another person breathes it in. It is more likely, however, that the person will develop a mild disease and not bronchopneumonia.

Breathing in microbes that pass into the lungs is normal. These microbes do not cause any disease in those with healthy immune systems. Nevertheless, it can become a problem for individuals with weak immune systems or underlying lung or heart disease. In these situations, it can lead to bronchopneumonia.

Symptoms may include coughing up mucus with or without blood, fever, shortness of breath, and fatigue.

Risk factors for this condition include infants and young children, people over 65, smoking, being bedridden, and underlying conditions such as flu, measles, cystic fibrosis, and chronic bronchitis.

Diagnosing bronchopneumonia includes a blood test and sputum culture to determine the causative microbe. An X-ray will be performed and, unlike lobar pneumonia, many small patches will be scattered around, often in both lungs.

Treatment of bronchopneumonia includes antibiotics and other measures, much like the treatment used for other types of pneumonia.

The severity of bronchopneumonia can range from mild to severe, and the prognosis is basically determined according to the severity of the underlying disease.

Documentation and Diagnosis Coding

In order to properly code for pneumonia, the coder needs to review the provider’s documentation for the type of pneumonia and its causative organism. It is up to the physician to specifically state the relationship between the pneumonia and the cause.

If the causative organism is not documented, the coder must use the ‘unspecified’ code. Furthermore, if the documentation is unclear, ambiguous, or inconclusive, the coder should consult with the physician.

In ICD-10, pneumonia code categories can be found in Chapter 10., Diseases of the Respiratory System (J00-J99), and specifically in J09-J18 Influenza and pneumonia. There are several code categories and combination codes for pneumonia. If an underlying condition caused the pneumonia, the documentation should also indicate that.

When assigning the ICD-10 code, the coder needs to apply all coding guidelines.

Coding examples

Documentation states:

Discharge diagnosis of lobar pneumonia due to pneumococcus
- Look in the ICD-10-CM Alphabetic Index under Pneumonia, lobar, pneumococcal J13
- Verify it in the Tabular. J13, Pneumonia due to Streptococcus pneumoniae

Note: Pneumococcal pneumonia is also known as Streptococcus pneumoniae is also known as Pneumococcal pneumonia.

Discharge diagnosis of lobar pneumonia
- Look in the Index under Pneumonia, lobar (disseminated) (double) (interstitial) J18.1
- Verify it in the Tabular. J18.1, Lobar pneumonia, unspecified organism

Hospital exam confirmed acute right lower lobe pneumonia due to Streptococcus pneumoniae
- Look in the Index under Pneumonia, in Streptococcus, pneumoniae J13
- Verify it in the Tabular. J13, Pneumonia due to Streptococcus pneumoniae

When the documentation states acute right lower lobe pneumonia or pneumonia in the right lower lobe, the coder cannot assume it is lobar pneumonia. They are not the same. Lobar pneumonia is a specific diagnosis, whereas pneumonia in the right lower lobe refers to the location of the pneumonia.

Patient has pneumonia in the right lower lobe
- Look in the Index under Pneumonia, (acute) (double) (migratory) (purulent) (septic) (unresolved) J18.9
- Verify it in the Tabular. J18.9, Pneumonia, unspecified organism.

Likewise, if the diagnosis provided is pneumonia and there is no further detail provided, J18.9 should be assigned.

Patient is diagnosed with Bronchopneumonia due to H. influenzae
- Look in the Index under Pneumonia, broncho-, bronchial (confluent) (croupous) (diffuse) (disseminated) (hemorrhagic) (involving lobes) (lobar) (terminal), Haemofilus influenzae J14
- Verify it in the Tabular. J14, Pneumonia due to Haemophilus influenzae

As stated previously, lobular pneumonia is also referred to as bronchopneumonia and is different from lobar pneumonia.

Patient is being seen for bronchopneumonia
- Look in the Index under Pneumonia, lobular — see Pneumonia, broncho. Then look under Pneumonia, broncho-, bronchial (confluent) (croupous) (diffuse) (disseminated) (hemorrhagic) (involving lobes) (lobar) (terminal) J18.0
- Or we can go straight to Pneumonia, broncho- if we know that lobular is under Pneumonia, broncho-
- Verify it in the Tabular. J18.0, Bronchopneumonia, unspecified

Be sure to read all the notes that correspond with each code, such as “Code First: associated influenza, if applicable (J09.X1, J10.0-, J11.0-),” “Code Also: associated abscess, if applicable (J85.1,),” “Excludes1” and “Excludes2,” and “Use additional” regarding tobacco use.

Conclusion

Pneumonia is a serious and potentially fatal condition. Therefore, the coder must assign the specific ICD-10 code that reflects the severity, acuity and risk of mortality. In addition, the coder must understand the different types of pneumonia, such as lobar pneumonia and bronchopneumonia. Finally, the coder needs to be able to apply the coding guidelines and select the appropriate code based on what is documented, such as Pneumonia due to Streptococcus pneumoniae or Pneumococcal pneumonia.

Debbie Jones is an administrative specialist for CCO, who has a passion for writing about medical coding and healthcare. She is the writer behind Medical Coding Buff, a new blog about medical coding.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682800/
https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204
https://articles.mercola.com/pneumonia/types.aspx
http://www.pathologyatlas.ro/pulmonary-pathology.php
https://www.ehealthstar.com/conditions/pneumonia/lobar
http://www.outsourcestrategies.com/blog/2016/08/good-documentation-practices-for-pneumonia-coding-reimbursement.html
http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/
http://www.hcpro.com/content/31647.pdfconversely