Topic: Know how to query physicians for specific pneumonia diagnoses
HIM Connection, May 13, 2008
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Hospital-acquired and community-acquired pneumonias do not translate directly to medical codes. When querying a physician, ask him or her to identify the organism (e.g., gram negative, Proteus mirabilis, Klebsiella, or aspiration) that caused the pneumonia. Physicians should specify the pneumonia’s causative agent. Coders and clinical documentation improvement specialists may see physician documentation that indicates “suspected” or “presumed.” Very often, cultures for pneumonia are unreliable. This unreliability may be due to the quality of the culture, or it may be because the patient has presented to the hospital after a failed round of antibiotic therapy at home.
Consider the following classic scenario for suspected aspiration pneumonia (complex pneumonia): An elderly patient with a history of CVA is admitted for pneumonia. Chest x-ray reveals right upper lobe opacities that are consistent with aspiration pneumonia. The patient undergoes swallow studies and is scheduled for PEG placement. The physician also treats the patient with gram-negative IV antibiotics. Until the physician or physician extender writes suspected or presumed aspiration pneumonia, a coder cannot report it and instead should query the physician.
Always look at the IV antibiotics that the physician ordered. Do you suspect that the pneumonia is complex because of the antibiotics that the physician selected? Again, this is a query opportunity. Unlike physician billing rules, coders in an inpatient setting can report conditions that are suspected or presumed.
Editor’s note: This article was excerpted from HCPro’s book, "The Clinical Documentation Improvement Specialist’s Handbook." For more information or to purchase a copy, visit www.hcmarketplace.com/prod-5975.html.
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