AHA Coding Clinic® for ICD-9 - 1987 November - December
Q & A
The physician's diagnosis is "Acute respiratory failure due to acute bilateral interstitial pneumonia due to Mycoplasma organism?" The discharge summary states: "Since we could not culture anything and since Legionella antibodies were negative, it was presumed that his pneumonia was due to Eaton's agent and he was given erythromycin as part of his antibiotic program with final improvement in the pneumonia and hypoxia." It was felt that the use of two codes was indicated, 136.3 for acute interstitial pneumonia and 483 for Mycoplasma pneumonia, to show the type of pneumonia as well as the organism. Is this correct coding? ...
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Article Overview
This short Q&A article focuses on how to interpret physician and discharge-summary language for a pneumonia case and whether more than one diagnosis code was appropriate under the guidance in effect at the time. It is relevant to coders, CDI specialists, and audit staff who work with historical ICD diagnosis coding and documentation interpretation.
Why This Topic Matters
Historical coding guidance can affect record abstraction, retrospective audits, and the accuracy of coded data sets. This article helps readers understand how one documented respiratory infection scenario was treated in the coding references available at the time.
What You Will Learn
- How the article frames a pneumonia-related coding question from physician and discharge documentation
- Why organism-associated respiratory diagnoses may require careful review in historical coding guidance
- How coding references may change across effective dates for diagnosis coding topics
- How to approach retrospective interpretation of older ICD diagnosis documentation
Who Should Read This
- Medical coders
- Coding auditors
- CDI specialists
- Health information management professionals
Codes Discussed
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