Health Information Management

Q&A: When is it appropriate to query for aspiration pneumonia?

CDI Strategies, January 5, 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 then queried the physician for aspiration pneumonia. I'm an inpatient coder, and we had a different viewpoint on this, and I wanted to get someone else’s insight on this topic.

A: This may be on the cusp of leading according to very conservative experts. I might suggest asking the physician, “Please clarify whether there is there 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 the physician administered were ceftriaxone and azithromycin, then the physician is not treating aspiration pneumonia and it would be a leading query and inappropriate to pose this question.
Editor’s Note: Robert S. Gold, MD, CEO of DCBA, Inc. in Atlanta and a member of the ACDIS advisory board answered this question for Contact him at

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