Health Information Management

Q&A: Coding for pneumonia with malnutrition secondary to feeding difficulties of the elderly

HIM-HIPAA Insider, March 20, 2012

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Q: A physician admitted a patient with pneumonia, which was the first diagnosis. The second diagnosis was malnutrition secondary to feeding difficulties of the elderly. Two days later, the physician inserted a percutaneous gastrostomy tube. A day or two later, the physician documented only that the patient had aspirated. Our clinical documentation analyst queried the physician for aspiration pneumonia. The inpatient coders wanted your insight.

A: This may be on the cusp of leading, according to very conservative experts. Consider this query: “Please clarify whether there is a link between the patient’s pneumonia and the aspiration you described.”
 
A physician query would be credible only if the antibiotics the physician documented prescribing were appropriate for aspiration pneumonia. If the antibiotics were ceftriaxone and azithromycin, the physician is not treating aspiration pneumonia and this is a leading query.
 
Editor’s note: Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta,answered this question in the March issue of Briefings on Coding Compliance Strategies.

 



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