Q&A: Coding pneumonia with dyspnea

Q: If the principal diagnosis is pneumonia, do I need to also code the symptom dyspnea? Or, is the dyspnea integral to the pneumonia? 

A: If the dyspnea (and as other examples: cough, mild shortness of breath, pain with breathing, etc.) is related to the pneumonia, then you would report the code for pneumonia, only, as a general rule. For example, though, respiratory failure is not integral to pneumonia, so that could be reported separately. Another example might be respiratory acidosis which is not always integral to pneumonia. 

If, however, the dyspnea was not related to the pneumonia but rather some other diagnosis which it is not intrinsic to (say, the dyspnea is being caused by renal acidosis), then you would need both the acidosis and the dyspnea codes to fully describe the condition. 

It’s true that there is some subjectivity that goes on here and the system is assuming that the coder has a great deal of pathophysiology knowledge and/or the physician documented the record by describing the entire pathophysiology process clearly. We know in the real word, however, that is not always the case. There are times when you get vague symptoms which may or may not occur with several diagnoses (such as pain). In these instances, the coder would/could not be certain which diagnoses go with which symptoms and may become confused as to what to report. 

For this reason, we routinely teach that the gold standard would be for the physician to actually link the signs and symptoms with the disease process. 

Let’s look at some examples.

Example one:

The physician documents the following: “Patient presents with cough, painful respirations, fever, dyspnea, and found to have pneumonia.

In this case, you would only report pneumonia.

Example two:

The physician documents the following, in addition to the first example: “Patient also presented with confusion, acidosis, thirst, and elevated glucose and found to be in diabetic ketoacidosis (DKA).”

In this case, you would only report acidosis. Notice here how the acidosis was not related to respiratory compromise as one might assume but instead was part of the DKA? 

Contrast that with the following: “Patient presents with chronic obstructive pulmonary disease (COPD) exacerbation and found to be acidotic”

In this case, you would report COPD exacerbation and acidosis—as not all COPD exacerbation patients are acidotic, both can be reported.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.