Final answer:
Codes should be assigned based on the definitive diagnosis made; if pneumonia is confirmed, a diagnostic code for pneumonia is used, otherwise, the coder should assign a code for the symptoms. Pneumonia is an inflammatory lung condition caused by various pathogens, with treatment typically involving antibiotics.
Step-by-step explanation:
If a diagnosis of rule-out pneumonia with cough and malaise is specified in an emergency department visit, the coder should assign codes for what is documented as definitive, not for the symptoms of cough and malaise since they are part of the pneumonia workup. Due to the conventional coding guidelines that dictate coding based on physician documentation, if the emergency department diagnosis is specifically to rule out pneumonia, and no definitive diagnosis is made during that visit, the coder usually assigns a code for the signs and symptoms (cough and malaise). However, if pneumonia is confirmed or identified as the diagnosis, the coder should assign a code specifically for pneumonia.
Pneumonia is an inflammatory condition of the lung primarily affecting the alveoli and can be caused by infections such as viruses, bacteria including Streptococcus pneumoniae, and other pathogens. It presents with symptoms of malaise, cough, and in advanced cases, may cause issues such as hypoxemia. The treatment often involves the use of antibiotics and can be more severe in immunocompromised patients, such as those with chronic conditions or those undergoing treatments that affect the immune system.