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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
        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
        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.
      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.
      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
Chronic renal failure
Pulmonary embolism
Sepsis or septicemia
Respiratory insufficiency or failure

Procedures Performed
Mechanical ventilation
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
     Gentamicin
     Tobramycin
     Amikacin
     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

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