Q&A: Selecting ICD-10-CM codes for aspiration pneumonia and related conditions

Q: A patient with severe emphysematous bronchitis is hospitalized due to acute RSV bronchitis. He is noted to have a history for cerebrovascular accident (CVA) with residual oropharyngeal dysphagia occurring in the past year and on day three of the hospitalization, he aspirated some of his breakfast during an episode of severe coughing. The patient’s RSV swab is now showing negative, so viral bronchitis is considered resolved, but the patient continues to require treatment for secondary aspiration pneumonia, which is their main concern at this point, as well as acute hypoxic respiratory failure. He will require oxygen continuously. How would this diagnostic note be reported in ICD-10-CM?

A: The ICD-10-CM codes for this encounter are:

• J69.0, Pneumonitis due to inhalation of food and vomit
• T17.910D, Gastric contents in respiratory tract, part unspecified causing asphyxiation, subsequent encounter
• J96.01, Acute respiratory failure with hypoxia
• J44.89, Other specified chronic obstructive pulmonary disease
• I69.391, Dysphagia following cerebral infarction
• R13.12, Dysphagia, oropharyngeal phase
• Z99.81, Dependence on supplemental oxygen

The primary condition listed is aspiration pneumonia but based on the diagnostic note, what did the patient aspirate on? His food during breakfast. Yet if a patient has choked on food that they coughed up or threw up, coders would consider this as gastric contents rather than food alone. At this point, coders should use the 2025 ICD-10-CM Alphabetic Index to make sure the correct code is identified. Locating the main term “pneumonia” and subterm “aspiration” leads to ICD-10-CM code J69.0, and there is a note to also code any associated foreign body in the respiratory tract using category T17.-, Foreign body in respiratory tract. It is not specified which part of the respiratory tract was affected and because the patient was coughing when they aspirated on the food, a code from subcategory T17.910-, Gastric contents in respiratory tract, part unspecified causing asphyxiation, would be used. A seventh character would be required to complete the code.

The secondary condition is acute hypoxic respiratory failure. Referring again to the alphabetic index, coders should locate the main term “failure” and subterms “respiratory” and “acute with hypoxia” to find the exact code J96.01.

Now we can focus on coding the other conditions listed in the note. The first condition listed is severe emphysematous bronchitis followed by RSV bronchitis, but it should be noted that the RSV bronchitis is resolved and not to be coded. Locating the main term “bronchitis” and subterm “emphysematous” leads to code J44.89. There is a note to also code a type of asthma, but this is not applicable as no asthma was documented for this case.

We note that the CVA with residual dysphagia is an old condition but is resulting in current acute issues and therefore is coded. Reiterating that the dysphagia was following a stroke, coders should locate the subterm “following cerebral infarction” under the main term “dysphagia” in the alphabetic index. This leads to code I69.391, which does have a note to use an additional code to identify the type of dysphagia, if known. The note specified the dysphagia was in the oropharyngeal phase, hence code R13.12.

Lastly, the patient’s dependence on long-term oxygen will have to be coded as well, which would be coded as Z99.81, Dependence on supplemental oxygen.

Editor’s note: This question and answer were excerpted from the DecisionHealth webinar, “Get a Grasp on 2024 COPD Code Changes,” presented by Brandi Whitemyer, RN, CDIP, COS-C, HCS-D, HCS-O, an independent home health and hospice coding consultant with expertise in post-acute billing and coding education, and was originally published on JustCoding.