healthcare vs aspiration PNA

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
When you have documentation of pneumonia: "healthcare vs aspiration related" do you code both?

Thanks!

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

Comments

  • lsipos@monument.healthlsipos@monument.health
    edited March 2016
    Isn't there the rule of "vs" so long as it isn't preceded by a SYMPTOM?

    Juli
    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    Yes. I would code both. Just checking. I am auditing and seeing that this is inconsistent.

    Thanks!

    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

  • dbeiseldentondbeiseldenton
    edited March 2016
    I'll take a stab at this one. I would say NO to your question based only on that documentation alone.

    I think you might be referring to the Coding Guideline that states if there are two or more comparable or contrasting conditions, both can be coded and either diagnosis may be sequenced first. This is not a comparable/contrasting situation.

    Based on documentation only of "healthcare vs aspiration pneumonia" which both are describing a Pneumonia. There is an old ICD-9 Coding Clinic describing a bacterial PNA superimposed on an aspiration PNA whereby they said you can code if both are treated.

    I think I would query for causal organism treated and get more clarification first.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    All cultures were negative on this patient. She did have a recent prior hospitalization for PNA where the bronch showed yeast and sphingomonas, she had improved with treatment and then returned approx. a week later. On this current admission she was treated with IV vanco and Zosyn. Pulm recommended an open lung bx but the patient declined. She has significant dementia with extensive history of dysphagia and acid reflux.

    I understand that we are likely talking about one pneumonia with two possible types. It is not the same as a superimposed bacterial PNA on aspiration PNA. But if the physician documents at discharge that both are on the differential how do we choose which to code if only one is to be coded? This patient has an MCC already but the DRG is dependent on the type of pneumonia as PDx. Respiratory infections vs simple pneumonia.

    Our MD's will not identify a causal organism without cultures (I know, I know...)

    Thanks!

    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

  • dbeiseldentondbeiseldenton
    Pneumonia, Unspecified Organism J18.9 has an Excludes 1 note for aspiration PNA, NOS J69.0. I personally would code the more specific descriptive Pneumonia of aspiration pneumonia with those clinical indicators as PDx.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited March 2016
    Ahhhh!!! I did not notice this. Thanks!

    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


  • Unknown
    edited March 2016
    When you say "hospital acquired pneumonia" which codes to a simple pneumonia versus "aspiration pneumonia," you ARE saying that it's pneumonia of one kind or the other and neither has been proven. So it's really a symptom followed by differential diagnoses. Differential diagnoses, strictly speaking, are NOT the same as "comparative and contrasting" because it's not known if the patient has either. It is certain that the patient has pneumonia, so the code should be that of pneumonia, unspecified at this time. However, with the history you give, this is a great opportunity to seek help from the doc. Physicians often miss the fact that aspiration pneumonia can be community acquired or healthcare acquired - and in the different venues, the organisms likely causative are different. So it is possible that this patient has healthcare acquired aspiration pneumonia. If the doc cannot give you "aspiration" pneumonia, then it must be pneumonia, unspecified in the absence of an organism. (There is no such thing as "gram negative pneumonia" in any medical textbook in the world)

    Robert S. Gold, MD
    CEO, DCBA, Inc
    4611 Brierwood Place
    Atlanta, GA 30360
    (770) 216-9691 (Office)
    (404) 580-0204 (Cell)

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