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RESPIRATORY CONDITIONS - DOCUMENTATION TIPS The issue regarding the coding of pneumonia is one of the most frequent problems encountered by hospital inpatient coders. It is problematic because of the lack of physician documentation on the organism causing the pneumonia when the causative organism is known or suspected and the complexity of the ICD-9-CM diagnosis codes and coding guidelines for pneumonia. The following represent the major issues affecting this DRG pair: Failure of the physician documentation in clearly confirming the type (bacterial versus viral or aspiration) and organism causing pneumonia (gram-negative versus gram-positive) after study Presence of coexisting conditions such as septicemia on admission, and lack of support of physician documentation to determine sequencing of principal versus secondary diagnoses, which may or may not be equally treated. Symptoms of pneumonia overlap with other chronic forms of respiratory disease such as acute bronchitis and chronic obstructive pulmonary disease. Initial Testing Blood cultures performed within 24 hours prior to or after hospital arrival (and before initiation of antibiotic therapy) Sputum cultures obtained prior to initiation of antibiotic therapy Chest x-ray Oxygenation assessment - O2 saturation (or ABG if indicated) CBC Diagnostic Testing Chest X-ray Should show infiltrates Rare false-negative results in patients with: dehydration, profound neutropenia and patients that are evaluated in first 24 hours Pneumonia due to PCP: negative chest films in 10-30% of cases CT scans can detect infiltrates that may not show up on plain film x-rays. Useful in detecting interstitial disease and emphysema Chest X-ray pattern of localized disease w/consolidation usually indicates bacterial infection. X-ray interstitial pattern more likely to represent viral, PCP, drug, or radiation pneumonia. Lab Need: growth in uncontaminated specimen, positive results of serologic tests, or detection of established pathogen that does not colonize the respiratory tract in the absence of disease (not normal flora*). Specimen must have presence of lower airway secretions. ABGs Hypoxemia with partial pressure 02 <60mm Hg on room air is usually standard criteria for hospital admission and supports consideration of admission to ICU. Community Acquired and other forms of Simple pneumonia – The following is a list of diagnoses that group to this category: Viral pneumonia Pneumococcal pneumonia Hemophilus Influenza pneumonia Streptococcus pneumonia Bacterial pneumonia, unspecified organism Pneumonia, due to other specified organism Bronchopneumonia, organism unspecified Pneumonia, organism unspecified Influenza, with pneumonia Pleurisy, without mention of effusion or current TB Clinical Indicators for Aspiration Pneumonia Impaired gage reflex Esophageal obstruction Dysphagia Positive CXR – lower lob infiltrate Current aspiration Recent or recurring vomiting Positive swallowing study PEG, NEG tube, or enterostomy status Past history of aspiration pneumonia or recurrent episodes of pneumonia Nursing home patient Status post CVA Debilitated or bedridden patient Alzheimer’s disease – dementia Clinical Criteria for Gram Negative and Other Serious Pneumonia Recent surgery, trauma or intubation Serious underlying disease or chronic illness (cancer, alcoholism, COPD, cardiac failure, uremia) Worsening of cough, dyspnea, reduction of oxygen level Treatment with immunosuppressive drugs Chronically debilitated patients due to conditions such as alcoholism, chronic renal failure, malnutrition, or advanced age Patients may be from high-risk settings such as recent hospitalization, nursing home, exposure to a known community epidemic such as with staph, or recent airway instrumentation such as bronchoscopy. Infiltrates in multiple lobes of the lung, i.e.: bilateral infiltrates, right lower and middle lobe infiltrates Recent outpatient antibiotic treatment with broad spectrum antibiotic with poor response Increased hospital length of stay The following findings in debilitated, chronically ill, or aged patients may suggest gram negative pneumonia: o Worsening of cough o Dyspnea o Fever o <02 level o Purulent sputum o Elevated leukocyte count or a normal count Note: A culture of expectorated sputum may be of limited value in the diagnosis of the agent causing acute pneumonia, especially when antibiotics have previously been administered. In the absence of confirmatory cultures, physician documentation of presumed or suspected gram-negative pneumonia in addition to the supporting clinical indicators within the body of the medical record will support the diagnosis of “gram-negative pneumonia”. Common gram negative organisms: Klebsiella (alcoholics, recent hospitalizations) Serratia Legionaries Pseudomonas (anaerobic) E coli (anaerobic) Enterobacter (anaerobic) Proteus (anaerobic) Other Co-morbid Conditions that effect severity COPD – emphysema, asthma, chronic obstructive bronchitis Bronchiectasis IDDM Malignancies Immunosuppression CHF Alcoholism Chronic renal failure Malnutrition HIV Pulmonary embolism Sepsis or septicemia Respiratory insufficiency or failure Dehydration IDDM Procedures Performed Intubation Mechanical ventilation Tracheostomy Bronchoscopy with or without biopsy Transtracheal lung biopsy Open lung biopsy Other considerations *Does the patient have another condition co-existing at the time of admission that may be equally responsible for occasioning the admission of the patient to the hospital that should be used as the principal diagnosis? Acute respiratory failure Sepsis or septicemia Congestive heart failure Respiratory neoplasm HIV with opportunistic lung infection such as pneumocystosis candidiasis of the lung *Code assignment is always based on the physician’s documentation. If pneumonia is documented by the physician in the body of the medical record and there is a positive sputum culture the physician must document confirmation of whether or not the organism discovered on the positive culture is the causative organism i.e.: Pneumonia due to Proteus Morganii, Aspiration due to aspiration, Staphylococcus pneumonia, Viral pneumonia, Bronchopneumonia due to streptococcus pneumoniae Drugs/ Therapies for complex or gram-negative pneumonia Treatment: Combination therapy such as gentamicin, tobramycin or amikacin in combination with cephalosporin (cefoxitin, cefobid, fortaz), or broad spectrum antibiotics or both. Third generation Cephalosporins Cefobid Fortaz Clalforan Rocephin Extended Spectrum Penicillin Piperacillin Ticarcillin Timentin Aminoglycosides Gentamicin Tobramycin Amikacin Other Primaxin Azactam Cipro (IV) NOTE: Antibiotics such as Erythromycin, Penicillin, Ampicillin, or Tetracycline usually indicate treatment for a simple pneumonia. Discharge Documentation Influenza vaccination Pneumococcal vaccination Smoking cessation advice/counseling Oxygenation assessment prior to discharge
"DOCUMENTATION TIPS DRG OPTIMIZATION POTENTIAL septicemia"