One condition in particular is supposed to be assigned 514, however, and another related condition is not. The problem is that a physician can use the exact same terms to describe both conditions. Still, one is right and one is wrong, and we have to be very careful, diligent and instructional to make sure that folks know that there is a difference and that they will be “queried” from here to tomorrow about every case they call “hypostatic pneumonia” – at least until they get into a routine of using that term when they mean what the code means, or until they can clarify that it doesn’t mean what the code means.


Let us return to the thrilling days of yesteryear in the U.S., before antibiotics: the late 1700s through mid-1800s. People used to die lingering deaths due to various diseases (they still do), alone in bed, friends visiting or ignoring them (same as today). These ailments usually would consist of neurologic disorders including stroke, demyelinating diseases, degenerative nerve diseases, malignant diseases with progressive weakness, liver failure, heart failure or renal failure. Because there were not adequate treatments or knowledge of methods of making patients more comfortable as they died, people tried various concoctions and remedies, from starving to potions to unguents – but not mobilization and not nutrition.


Take a look online and you’ll find innumerable references to people in the 1800s whose surviving records showed that they died with hypostatic pneumonia. This still happens today in Africa and other in less medically savvy countries around the world. People essentially still are permitted to deteriorate and die. They almost all have decubiti, and almost all have massive malnutrition. And in the face of virtually total bed rest or immobilization, with lack of proteins, decreasing cardiac output as the heart fails and massive decreases in respiratory function, blood aggregates in the dependent portion of the lungs (not always in the bases of the lungs) and causes congestion. This is referred to as “hepatization” of the lung. Instead of a soft, pliable tissue that crackles when you touch it, the lung tissue becomes firm, as hard as the liver and with no pliability whatsoever. And with the decreased oxygenation that accompanies this formerly functioning lung, there is even less chance to heal or to supply organs with needed oxygen to carry on routine functions As such, the patient declines further. You can see pictures of this in pathology textbooks. It’s a classic.


This is hypostatic pneumonia. It is usually totally asymptomatic in patients and often is found incidentally through postmortem exam. If it becomes infected, it may hasten death through lung abscess formation.


Current references to “hypostatic” pneumonia (and it’s frequently referred to with accompanying quotation marks, interestingly) cite pneumonias affecting humans or animals after anesthesia or other temporary conditions of decreased activity with possible decreased respiratory excursions (meaning that you don’t breathe as deeply). These descriptions are referring to the atelectasis that can occur after surgery or with inadequate depth of breathing for whatever reason, and the pneumonia that may emerge in those patients. There is no indication of the massive, prolonged changes that go into the condition properly assigned as ICD-9-CM code 514. Most of the current articles you may read talk about early mobilization, use of incentive spirometry and limitation of narcotics to avoid “hypostatic” pneumonia, which is infection affecting patients with unclearing atelectasis and accumulation of secretions.


Take a look at these two pictures and see if either represents a patient with diastolic dysfunction as a background, presenting in stable condition with a cough and fever and with an X-ray that shows an infiltrate that is diagnosed as pneumonia. Is there any possibility that this represents the new version of “hypostatic” pneumonia? And is there any remote chance that this is represented by ICD-9-CM Code 514 and deserves a DRG assignment of 189, rather than what it should be? You can make up your own mind, but personally, I’d be pretty careful.


Look at the ICD-9-CM book. Pulmonary congestion is a finding presenting upon physical examination or existing as a historical symptom, and is not to be assigned Code 514. Pulmonary edema is either a finding on an X-ray not to be assigned 514 or represents acute pulmonary edema, deserving the proper code for that condition. Hypostatic pneumonia often is a finding emerging on postmortem examination, and no patient ever is admitted to a hospital for that condition.


Think about it.


About the Author


Robert S. Gold, MD, is a nationally known physician, responsible for having championed Clinical Documentation with his peers and hospital organizations. Dr. Gold is a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper reimbursement


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