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By Lisa A. Eramo, MA for For the Record
Why Your Hospital’s Reputation Depends—at Least Partially—on Accurate Pneumonia Coding
These days, it takes seconds for patients to view mortality and readmissions data on the Centers for Medicare & Medicaid Services’ Hospital Compare website (www.medicare.gov/hospitalcompare). With a few clicks of the mouse, they can—and frequently do—draw conclusions about the quality of care that’s provided.
Pneumonia, which causes approximately 1 million hospital admissions annually, according to the Centers for Disease Control and Prevention, is one of several diagnoses listed on Hospital Compare. Coded data are what drives these publicly reported quality measures, making it imperative that organizations undertake a concerted effort to correctly capture diagnostic specificity and sequence conditions.
All cases with a principal diagnosis of pneumonia are included in the 30-day risk-standardized pneumonia readmission measure as well as the 30-day risk-standardized pneumonia mortality measure. Cases with a principal diagnosis of sepsis (with the exception of severe sepsis) and a secondary diagnosis of pneumonia coded as present on admission (POA) are also included in these measures when there is no additional secondary diagnosis of severe sepsis (ie, R65.20 [severe sepsis without septic shock] or R65.21 [severe sepsis with septic shock]) coded as POA.
“The bottom line is that all pneumonia codes are on the hook for mortality and readmissions,” says James P. Fee, MD, CCS, CCDS, CEO of Enjoin. “Aspiration pneumonia used to be the only one that was excluded, but now it’s also included.”
(For a complete list of ICD-10-CM codes as well as inclusion/exclusion criteria and risk adjustment for both pneumonia measures, visit the QualityNet website at www.qualitynet.org.)
Hospitals need to understand that these data drive consumer decisions about where to receive healthcare services, says Dee Mandley, RHIT, CCS, CCS-P, CDIP, lead educator at Peak Health Solutions. “Anyone can go on this site and compare hospitals based on pneumonia information, so you need to make sure that it’s coded correctly.”
In addition to quality measure implications, pneumonia coding affects reimbursement and length of stay. For example, unspecified pneumonia maps to diagnosis-related group (DRG) 195 (simple pneumonia and pleurisy without complication or comorbidity [CC] or major CC [MCC]) with a relative weight of 0.6868 and 2.6-day geometric length of stay. The more specific aspiration and certain specified bacterial pneumonias both map to DRG 179 (respiratory infections and inflammations without CC/MCC) with a relative weight of 0.9215 and 3.2-day geometric length of stay.
When reported as a secondary diagnosis, pneumonia carries an MCC status and can have a positive effect on the final Medicare severity DRG (MS-DRG) assignment, Mandley says. Pneumonia also carries a severity of illness rating of three and a risk of mortality rating of two, both of which have a positive effect on all patient refined DRG assignment, she adds.
When it comes to accurate pneumonia coding, conflicting documentation is one of the biggest challenges for coders, says Darina Kutish, RHIT, CCS, vice president of coding operations. “Some doctors will call it pneumonia, some will call it an infiltrate based on the X-ray, and some may say bronchitis. The documentation makes some of these cases very difficult to code.”
Coders must recognize clinical indicators of pneumonia and query when necessary, Kutish says. For example, symptoms such as fever, cough, shortness of breath, pleuritic chest pain, and respiratory distress can be clues that pneumonia is present. Other clues include a physical exam that shows rails, rhonchi, and abnormal breath sounds. The patient may also have an elevated white blood cell count and a chest X-ray showing consolidation, an infiltrate, and/or interstitial changes. Finally, the sputum culture may be positive for an organism.
“These are all good clinical indicators to back up the pneumonia. The sputum cultures do not need to be positive, but if they are, it can help support a query,” Kutish says.
According to Mandley, another challenge is identifying the principal diagnosis when the patient has multiple pulmonary conditions on admission such as respiratory failure, COPD, and pneumonia. Coders must think carefully when assigning pneumonia as the principal diagnosis because doing so means the case will potentially be included in the 30-day readmission and mortality measures. When in doubt, a query to the physician is necessary, Mandley says.
When multiple conditions are POA and all meet the definition of principal diagnosis, coders have the flexibility to choose the diagnosis that will yield the highest-weighted DRG, Kutish says. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” For example, when pneumonia and acute respiratory failure are both POA and meet the definition of principal diagnosis, coders can report the pneumonia as the principal diagnosis with acute respiratory failure as a secondary MCC.
Scenario-Specific Pneumonia Coding Tips
Experts say pneumonia can present in many different ways; the clinical circumstances of each case will drive ICD-10-CM code assignment and sequencing. The following are several common scenarios with tips for compliant coding.
Coders should report ICD-10-CM code J18.9 when the cause of pneumonia is unknown. This can occur when sputum cultures are negative. Coders should also report J18.9 when physicians document one of the following conditions: community-acquired pneumonia, hospital-acquired pneumonia, or health care–acquired pneumonia, Mandley says.
Sputum cultures may be negative when patients receive antibiotics upon admission to the hospital and before cultures are taken or when the quality of the specimen is lacking, she adds. They may also be negative when patients are already on an antibiotic for another condition such as a urinary tract infection.
However, coders should always perform a thorough review of the record rather than default to an unspecified type, says Regina Jackson, CPC, CPMA, CPC-I, co-owner at EnR Coding Solutions. Doing so presents a more accurate clinical picture of severity of illness and risk of mortality, she says.
Pneumonia as a Manifestation of an Infectious Disease
When influenza causes pneumonia, coders should report a code from the ICD-10-CM J09.- through J11.- range. When the type of influenza is known—and physicians link the influenza with the pneumonia—report combination codes J09.- or J10.-. When the type of influenza is not known, report J11.-, says Elizabeth Hankins, CPC, CCS-P, CPMA, CPC-I, PMCC, co-owner and founder of EnR Coding Solutions.
Remember that patients can have more than one type of pneumonia simultaneously (eg, pneumonia due to influenza and pneumonia due to a bacterium). “You have to really carefully review the documentation on admission to see where the bulk of treatment is going,” Mandley says.
When coding tuberculosis that causes pneumonia, refer to the key term “pneumonia” in the alphabetic index and then the subterm “tuberculosis,” which directs coders to see “tuberculosis, pulmonary.” Thus, ICD-10-CM code A15.0 (tuberculosis of lung, including tuberculosis pneumonia) is appropriate, says Mary Frungillo-Tomak, CCS, CDIP, manager of inpatient coding, clinical documentation improvement (CDI) audit, and education at Atos.
Coders should report ICD-10-CM code J69.0 for aspiration pneumonia and be prepared to query physicians in the absence of explicit documentation when clinical indicators of aspiration pneumonia are present, according to Kutish. These include poststroke dysphagia and reflux disease as well as a swallowing study to assess the patient’s gag reflex or the presence of a nasogastric tube, she adds.
When there’s a positive sputum culture, physicians should link the specific organism causing the pneumonia so coders can choose the appropriate ICD-10-CM code for the bacterial pneumonia, Kutish says. “The doctor has to state the significance of that positive culture. If they don’t state that significance, then you cannot report the more specific code,” she explains.
The following is a sample statement that would allow coders to report ICD-10 code J15.5: “Patient has positive sputum culture for E coli and we’re treating them for E coli pneumonia.”
Mandley reminds coders to keep in mind that the type of bacterial organism can affect the final MS-DRG assignment. For example, gram-negative pneumonia maps to ICD-10-CM code J15.6, driving a respiratory infection DRG. Pneumonia due to Streptococcus pneumoniae maps to ICD-10-CM code J13, driving a lower-weighted simple pneumonia DRG.
Pneumonia That Causes Sepsis
When sepsis and pneumonia are both POA, coders should assign the sepsis as the principal diagnosis and the localized infection (pneumonia) as secondary per official coding guidelines, Frungillo-Tomak says.
These guidelines state: “If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.”
Pneumonia Due to Near Drowning
When a patient has pneumonia due to near drowning, coders should refer to the Excludes 1 note under ICD-10-CM code T75.1xx- (unspecified effects of drowning and nonfatal submersion) that instructs coders to code to the specified effects of the drowning (ie, pneumonia, J18.9), Kutish says.
Pneumonia With Acute Exacerbation of COPD
This situation requires the following codes: J44.0 (COPD with acute lower respiratory infection), J18.9 (pneumonia, unspecified organism), and J44.1 (COPD with acute exacerbation). Previously, J44.0 had a “use additional code” note to identify the infection, meaning coders were required to report the pneumonia code as a secondary diagnosis.
“Now there is a ‘code also’ note that does not denote sequencing. Therefore, you may sequence either one as the principal diagnosis depending on the circumstances of the admission,” Kutish says.
Tips to Promote Pneumonia Data Integrity
Experts share the following tips to ensure that coded data reflect pneumonia specificity:
• Provide coder education. Recruit a physician champion to educate coders about the types of pneumonia as well as causes, risk factors, signs, symptoms, complications, and treatment, Mandley says.
“Without knowledge of the disease, a coder is unable to analyze the clinical documentation in the medical record and recognize the need for a physician query to capture specificity of the diagnosis,” Frungillo-Tomak says. “It’s also necessary to compose a compliant query.”
• Provide physician education. A physician champion can educate physicians about pneumonia documentation requirements such as causative organisms, pneumonia type, and any associated conditions (eg, acute exacerbation of COPD and the presence of influenza), Mandley says.
“For inpatients, documentation of possible or probable diagnoses infers a strong clinical suspicion and can be coded as present,” she notes, adding it’s a good idea to incorporate documentation education into the orientation schedule for new residents and to post documentation tips and fliers in patient care areas.
• Use denials as teaching tools. Ask coders and CDI staff to review these cases so they understand why denials occur and how to prevent them proactively, Mandley says. For example, payers may assign a lower-weighted DRG if the POA indicator for the pneumonia is incorrect (ie, reported as Y when it should have been N).
Some payers may also deny pneumonia when the chest X-ray is negative, making it critical to document and code all of the patient’s other pneumonia symptoms, Kutish notes. “Get that bulletproof documentation up front so payers can’t deny payment,” she says.
• Analyze pneumonia queries. Do coders and CDI specialists frequently query one or two physicians? Or do queries tend to address the same documentation problem across the board? “A CDI program can provide tremendous data for analyzing coding and documentation patterns,” Mandley says.
• Develop clinical indicators. Mandley recommends involving medical staff in identifying specific clinical indicators that CDI and coding staff can use when assessing the presence of pneumonia.
• Promote collaboration between coding and CDI. Consider scheduling a recurring meeting so staff can discuss diagnoses that the organization may be struggling to report correctly, Frungillo-Tomak says.
She says these meetings are ideal opportunities to do the following:
— Exchange knowledge. CDI specialists can provide clinical education on pneumonia to coders, and coders can educate CDI staff on the application of pneumonia-related coding guidelines and Coding Clinic quarterly updates.
— Review and standardize physician queries to reflect specific types of pneumonia.
— Use a standardized dispute process to discuss cases for which coders and CDI specialists disagreed on final DRG assignment.
“I think it’s important for coders, CDI specialists, and physicians to work together to get that documentation so you get the most accurate payment for the hospital,” Kutish says.