The entry in the Alphabetic Index for Pneumonia, basal, basic, basilar, instructs the coder to see Pneumonia, lobar. Lobar pneumonia is indexed to 481, Pneumococcal pneumonia. However, previous Coding Clinic advice states that it is inappropriate to assume the presence of an organism when the documentation cannot support the code assignment. Does this advice apply to basilar pneumonia too?
Basal (basilar) pneumonia is an infection of the lower segments of the lung. Since basilar pneumonia relates to the location of the infiltrate and not a specific organism, query the provider regarding the specific type of pneumonia and code accordingly. Assign code 486, Pneumonia, organism unspecified, if the provider is unable to provide further clarification as to the specific type of pneumonia or the specific organism involved. As of October 1, 2010, revisions to the index have been made and the coder is directed to "See Pneumonia, by type," when basal, basic, basilar pneumonia is referenced.