By Kathryn Fallah from ACDIS CDI Blog
According to the World Health Organization , pneumonia is a form of an acute respiratory infection that inflames the lungs. When CDI professionals review the record and ensure that the documentation of pneumonia is accurate and complete, they can impact reimbursement, risk of mortality scores, and risk adjustment. There are multiple types of pneumonia and etiologies, so knowing how to identify and code for each one is essential.
To prove pneumonia is present, a physician will write their physical assessment and then request a chest x-ray in attempt to visualize the pneumonia with the imaging. In some cases, the chest x-ray may be negative, but the patient still has pneumonia according to other diagnostics. Sometimes, the clinical indicators may not be present on admission (POA). If a patient comes in with another more acute issue, it could take a couple of days to diagnose their pneumonia. In this situation, a CDI specialist needs to study the symptoms a patient shows on arrival to support the diagnosis pneumonia, such as if they are complaining of a fever, lethargy, or shortness of breath.
When pneumonia is documented, the CDI specialist should ensure the documentation specifies the type and etiology to assign the most accurate code. Determining the code can be a challenge, however, since the identification of the organism is the key to determining the type of pneumonia present. Identifying all this information will influence the specific code and DRG assigned, which affects the patient’s risk of mortality and risk adjustment.
Pneumonia cases can be either simple or complex and assessing the type is necessary for accurate treatment and reimbursement. While it’s rare that a simple pneumonia case requires a hospital stay, a hospital admission would be necessary for a complex case since it requires multiple combination antibiotics and entails more multi-resistant organisms. For example, with complex cases of pneumonia, some symptoms to look out for are an exaggerated systemic inflammatory response syndrome (SIRS) response and high fever, an elevated white cell count, increased sputum production, and worsening respiratory status. Looking at your patient’s history, including where they have been, their presentation, and their response to antibiotics and treatment, will help you differentiate between a simple versus complex case.
A patient can either develop pneumonia inside the hospital, which is called hospital-acquired pneumonia (HAP), or outside the hospital, which is called community-acquired pneumonia (CAP). The vast majority of CAP diagnoses (roughly 85%) are due to three pathogens:
- S. pneumoniae
- H. influenzae
- M. catarrhalis
Regardless of whether the pneumonia was CAP or HAP, CDI professionals should query the physician to determine the pathogen causing the condition. Sometimes, a physician will write one or the other to differentiate between a simple versus complex case. Without knowing the underlying organism, a CDI specialist cannot determine the DRG.
If an associated organism is identified by the sputum culture, the provider can link the organism to the disease process to confirm pneumonia. However, sputum cultures can be inconclusive and are often not clinically necessary. Ultimately, pneumonia can empirically be diagnosed by a physician through patient assessment, risk factors, clinical findings, and response to treatment.
When a CDI specialist sees a patient with a pneumonia diagnosis, that’s where critical thinking must kick in—they should ask themselves a variety of defining questions to determine the right type and code. For example, is it clinically pneumonia despite a negative chest x-ray? Are you sure of a causative organism or class? Is the pneumonia related to a chronic lung disease, such as chronic obstructive pulmonary disease? These are the things you need to think of with every pneumonia course to determine the correct code assignment for accurate reimbursement and quality reporting. Make sure to include all evidence of your findings in the query as proof.