High number of simple pneumonia cases

shines

We are seeing a high number of cases that are coded to simple pneumonia (we are outliers now) . What other diagnosis could we try and get that pneumonia into? There are weak indicators present such as infiltrates on X-ray, afebile, empiric IV antibiotics, , no sputum or blood cultures. Is copd exacerbation a good alternative? And how would we as CDSs make a case for copd exac instead of pneumonia.?

cynthia.a.goewey

We query for the suspected organism the MD is treating if we see antibiotics other than our usual ceftriaxone and azithromycin to see if the patient may have a gram negative or other "complex" type pneumonia. We don't have great response from these queries despite education to our hospitalist group.
Cindy

katysuegood@gmail.com

We are a high-outlier as well. I audit this DRG quarterly. I think the primary concerns are:
1. Could this PNA be further specified to move it into the respiratory infections DRG (could the organisms be specified? Suspected aspiration?)
2. Could this patient have been treated as an outpatient?

COPD is a better DRG that PNA but obviously this only works if the patient really is being admitted for a COPD exacerbation.

I would recommend a retro audit of these records to determine what the opportunities could be as far as further specificity of the PDX and alternative Pdx options.



Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

vanessa.falkoff

Hi all,
I am in the same "simple PNA boat", we are trying educational queries on our PNA case, but rarely get anything more specific than bacterial.
Query attached- suggestions welcome!

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054

evanspx@sutterhealth.org

Regarding COPD as the PDX rather than some forms of PNA, this is permitted per Coding Clinic. See Reference:

Personally, I ensure the 'acute exacerbation of COPD' justifies the decision to list the COPD over the PNA as the PDX - If the COPD is not treated with IV meds , and the PNA IS treated with IV meds, I personally use the PNA as the PDX.

Must keep this statement in context: "In those rare instances when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines"




We also consider a query if/when a particular type of PNA is targeted as evidenced by antibiotic usage.

Reference: AHA Coding Clinic® for ICD-9-CM, 1Q 2010, Volume 27, Number 1, Pages 12-13

Question:
When a patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and an infection such as pneumonia, is pneumonia always sequenced as the principal diagnosis?

Answer:

Sequence either code 486, Pneumonia, organism unspecified, or code 491.21, Obstructive chronic bronchitis, with (acute) exacerbation, as the principal diagnosis, when the patient is admitted with both conditions. The pneumonia and COPD are two separate conditions that presented simultaneously. The pneumonia is not the exacerbation of the COPD.

The Official Guidelines for Coding and Reporting previously published in Coding Clinic, Fourth Quarter 2008, page 303, states “In those rare instances when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

jschoonhoven

Our best tool to address pneumonia documentation is the attached Pneumonia admission order sheet the hospitalists use. They wanted an addendum to the generic admission orders that would organize the normal orders for antibiotics. Since I'm on the forms committee I was able to influence the way the diagnoses were listed and this has been very helpful for us to capture greater specificity.
Note 'with Sepsis' is an option as well. Our elderly population often does present with that level of severity.
We periodically discuss in our educational meetings the antibiotics used for different diagnoses too. One can work backward to discover what the provider is trying to treat, and then ask them to spell it out!

Janice

Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network

katysuegood@gmail.com

This is great. I have seen some great order sets like this for PNA as well. Is this on paper in your charts or do you have an electronic format? If paper, do you have a plan for when you move to an EMR?

We used to have a few order sets when we were paper but once we went like with CPOE they went away. There are still some standard 'order sets' for certain dx (post-op major joint, for example) but they don’t include all the diagnostic info. They are just the actual med/tx order. And they do not look the same at all. The Coders would have to filter through an awful lot of orders to get anything meaningful out of them.

Any thoughts?

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

jschoonhoven

We are hybrid EMR and paper. Full Epic not until 2015 unfortunately!
We will do all the customizing we can in prep for Epic, but I am aware there is plenty of job security moving forward as it does bring new challenges while solving others..
Janice