Simple Pneumonia vs. Complex Pneumonia

sbourquesbourque
in Clinical & Coding
I have been told by our Infectious Disease physician that when a physician documents health care acquired or hospital associated pneumonia, the physician is treating a more complex pneumonia and not a simple pneumonia. Our PEPPER reports show that our hospital
s rate of DRGs 177-179 is below the state and national norms. We are trying to come up with physician education for the proper documentation for these complex pneumonias beside HCA pneumonia. Any suggestions???

Suzonne Bourque

Comments

  • mulled2mulled2
    edited May 2016
    You have to look at the meds they are using to treat these. And see if you can deduce whether it is MRSA, a gr neg bacteria, a pseudomonas, etc
    We have a very good cheat sheet of antibiotics through JATA



  • kerryseekircherkerryseekircher
    edited May 2016
    Agreed. I have something I can share with you. Feel free to email me.
    Also, go the forms and tools library on the ACDIS site and you will find a ton of resources on this topic.
    Thanks,
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP





  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited May 2016
    Kerry, please share with all.

    Kim Williams, RN
    Clinical Documentation Specialist
    Halifax Regional
    Revenue Management Department
    kwilliams@halifaxrmc.org
    (252) 535-8154
    (252) 535-8937 fax







  • sbourquesbourque
    edited May 2016
    Kerry,
    What is your email and phone #?

    Suzonne


  • kerryseekircherkerryseekircher
    edited May 2016
    Sorry!
    It's kseekircher@nwhc.net and ph. Is 914-666-1243.

    Kerry


  • christine.butka@hmhn.orgchristine.butka@hmhn.org
    We came up with a standarized query template that all of the CDI nurses use. It says "you are treating pneumonia with antibiotics (list them) not commonly used for CAP." In addition we put whatever additional information we see such that is a risk factor for HCAP (such as recent admission / nsg home patient, dialysis). We then ask the physician to document the suspected / likely organism they are treating and give them choices such as MRSA PNA, Pseudomonas PNA etc. At the end of the query we state that HAP or HCAP does not denote the type of pneumonia it only documents where the patient may have acquired the pneumonia. We have had physicians answering HCAP anyway and then our Physician Advisor has a talk with the doctors. She has been teaching them to document the suspected organism they are treating for. We have seen a lot of improvement with our DRG shift.

    Christine Butka RN MSN CCDS
    CentraState Medical Center
    Freehold, NJ
  • kerryseekircherkerryseekircher
    edited May 2016
    Hi Kim-
    See attached. This tip sheet is geared toward CDI and Coding Staff to help look for cues for complex pna.
    Thanks,
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP


  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited May 2016
    Thank you for sharing, Christine.

    Kim Williams, RN
    Clinical Documentation Specialist
    Halifax Regional
    Revenue Management Department
    kwilliams@halifaxrmc.org
    (252) 535-8154
    (252) 535-8937 fax







  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org
    edited May 2016
    Thanks so much Kerry! Being a one-woman show (still a "green stick") in a rural hospital... I count on you all so much.

    Kim


  • kerryseekircherkerryseekircher
    edited May 2016
    Hi Kim-
    Your welcome and best of luck!
    Kerry

    Kerry Seekircher, RN, BS, CCDS, CDIP




  • erica.allen@olathehealth.orgerica.allen@olathehealth.org
    Hi!

    I am a new CDI and I am the only one at a small rural hospital and I have recently joined ACDIS.  I love all the information that is available and to have other CDIs to network with.  Simple pneumonia vs. Complex pneumonia is one thing I working on right now to help educate our physicians on more specific documentation.  I would love any tips or tools anyone would have available and wouldn't mind sharing with me.  My email is erica.allen@olathehealth.org and my phone number is 913-294-6682image.  Thank you all!

    Erica
  • annnd2009@gmail.comannnd2009@gmail.com
    Often doctors chart HCAP PNA, which may mean more complex PNA, but if they are on Vanco and Zosyn or similar, ... doctors often feel how can they say gram negative ( or positive) without a culture when antibiotic selection covers both... I had always been fine with the mentality until recently when the same logic is questioned in other scenarios that don't have a definitive answer.  if you have multiple antibiotics one covering for more than , I.e, gram negative, is that okay? ethical stretch? depends on consultant or director advisement? curious, on programs take on the subject, and MD feedback?

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    I have often pondered this complex and advanced scenario and our team is extremely well-versed in regards to risk factors and context for complex versus simple pneumonia.  I am a bit reluctant to advocate a particular type of pneumonia if/when 'broad' coverage is provided to cover such a wide range of infective agents.  We discussed this with our MD mentor, an infectious disease specialist, he listened intently, and felt that posing a query is not proper given that the physician really does not know if the type of pneumonia may be gram negative or gram positive.  Rather, the best classification is simply bacterial. I am aware of the coding rules and CDI strategies on this topic..but, we no longer query for one type or the other in such situations and I must say it seems a bit aggressive to do so given neither classification is strongly suspected more than the other and the approach to 'kill multiple bugs' does not lend itself to precise coding.

    Paul Evans, RHIA,

  • xtofluxxtoflux
    i don't see any tipsheet- please specify

  • cselukecseluke
    paul_evans_90314 said:

    I have often pondered this complex and advanced scenario and our team is extremely well-versed in regards to risk factors and context for complex versus simple pneumonia.  I am a bit reluctant to advocate a particular type of pneumonia if/when 'broad' coverage is provided to cover such a wide range of infective agents.  We discussed this with our MD mentor, an infectious disease specialist, he listened intently, and felt that posing a query is not proper given that the physician really does not know if the type of pneumonia may be gram negative or gram positive.  Rather, the best classification is simply bacterial. I am aware of the coding rules and CDI strategies on this topic..but, we no longer query for one type or the other in such situations and I must say it seems a bit aggressive to do so given neither classification is strongly suspected more than the other and the approach to 'kill multiple bugs' does not lend itself to precise coding.

    Paul Evans, RHIA,

    Paul, we have taken a similar approach to the complex pneumonia dilemma. Our physician advisor takes a similar position to your ID doc; i.e., antibiotics used in HCAP are empiric in that they cover a broad spectrum of bacteria and the physician usually has no idea which particular organism they are treating. If you ask, they might answer "I'm covering for all possibilities." I do wish the pneumonia classification would change to include HCAP and CAP and not classify on the basis of organism.

    Cathy
  • hooter1964hooter1964

    Database

    Suspected Pathogen

    Alcoholism acute or chronic

    Streptococcus pneumoniae (including DRSP), anaerobes, Gram-negative bacilli, Mycobacterium sp

    Chronic obstructive pulmonary disease

    Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

    Recent viral infection

    Streptococcus pneumoniae, Staphylococcus aureus (including MRSA), H. influenzae, Gram-negative bacilli

    Nursing home (age >75 y)

    Gram-negative bacilli (including resistant ones such as Pseudomonas aeruginosa, Acinetobacter spp), S. pneumoniae, H. influenzae, aspiration (anaerobes), S. aureus, Chlamydophila, Mycobacterium tuberculosis

    AIDS (risk groups: intravenous drug abuser, hemophilia, homosexual)

    S. pneumoniae, Salmonella, cytomegalovirus, H. influenzae, Cryptococcus, P. jiroveci, anerobes, M. tuberculosis

    Hospital-acquired

    Gram-negative bacilli (including Pseudomonas aeruginosa), S. aureus (including MRSA)

    High-risk aspiration

    Anaerobes (if aspirate while not intubated), Gram-negative bacilli, chemical pneumonitis

    Cardiac disease

    S. pneumoniae, Gram-negative bacilli

    Neutropenia

    P. aeruginosa, Aspergillus sp, Gram-negative bacilli

    Recent antibiotic therapy

    DRSP, P. aeruginosa, MRSA (especially in HAP)

    Postinfluenza

    Pneumococcus, S. aureus (including MRSA), enteric Gram-negatives

    Endobronchial obstruction

    Anaerobes, Gram-negative bacilli

    Structural lung disease (cystic fibrosis, bronchiectesis)

    P. aeruginosa, P. cepacia, S. aureus

    DRSP, drug-resistant S. pneumoniae; HAP, hospital-acquired pneumonia; MRSA, methicillin-resistant S. aureus.
  • hooter1964hooter1964

    A review of published studies of the causes of pneumonia in hospitalized patients and the results of the SENTRY Antimicrobial Surveillance Program in the United States concluded that six pathogens cause approximately 80% of HAP cases .

    Staphylococcus aureus 30% (MSSA & MRSA)

    Pseudomonas aeruginosa 24%

    Klebsiella species 11%

    Escherichia coli 8%

    Acinetobacter 7%

    Enterobacter species 7%

  • smithdoolinsmithdoolin
    HELP? I just need a complete answer in one place as I am exhausted searching and not finding this exact scenario; maybe I am being too "OCD" about it but I figured if anyone could help, the forum could!
  • smithdoolinsmithdoolin

    jsd6978@comcast.net said:
    HELP? I just need a complete answer in one place as I am exhausted searching and not finding this exact scenario; maybe I am being too "OCD" about it but I figured if anyone could help, the forum could!

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
    jsd6978@comcast.net said:

    jsd6978@comcast.net said:
    HELP? I just need a complete answer in one place as I am exhausted searching and not finding this exact scenario; maybe I am being too "OCD" about it but I figured if anyone could help, the forum could!


    What was your question? I don't see a question from you previously on this thread.

    Jeff

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    Clues to look for in the documentation when a complex pneumonia is being treated:

    • Hospital Acquired Pneumonia (HAP)

    • Community Acquired Pneumonia; from nursing home-cover with broad spectrum and for atypicals

    • Pneumonia in a nursing home resident

    • Pneumonia in a patient with a recent hospitalization

    • Pneumonia in a patient with swallowing difficulties, dysphagia, history of CVA, dementia, other neurological disorders, elderly

    • Covering for Staph pneumonia (covering for is NOT the same as treating for)

    Common antibiotics used to treat complex pneumonia (often patients are on more than one):

    • Vancomycin (Staph/MRSA)

    • Zosyn (Gram-negative/Aspiration)

    • Azactam (Gram-negative)

    • Imipenem (Gram-negative)

    A few common types of complex pneumonia (MS DRG 177-179) are:

    • Aspiration Pneumonia

    • MRSA/Staph Pneumonia

    • Gram-Negative Pneumonia

    In contrast, simple pneumonia (MS-DRG 193-195) is often treated with:

    • Levaquin

    • Zithromax

    Other concepts to keep in mind when looking at pneumonia on admission:

    • Does the patient have Sepsis/Severe Sepsis?

       

    • If faced with the challenge of the MD not being able to confirm the diagnosis, it is acceptable for the physician to document “suspected” or “probable” though any possible diagnosis needs to be documented on the date of discharge and/or in the discharge summary in order to be coded.

       

    • When reviewing pneumonia cases, it is helpful to begin by looking at the antibiotics ordered; it will help determine the need for query in conjunction with other supporting clinical indicators as well as reviewing for Sepsis criteria.

       

    • Be mindful of querying for a complex pneumonia when one dose of Vancomycin is given in the ED and the antibiotics are later changed by the attending to Levaquin. *Look for consistency.

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