Pneumonia Discrepancy
We are having a discrepancy between our CDI and coding departments. What do you all think? Should pneumonia be coded or not?
CODER: If a physician (especially if it’s a specialist in the condition being evaluated) notes that an earlier suspected condition is ruled out and there is no other documentation that contradicts that statement, you are pretty safe in assuming that the patient did not have pneumonia. If in doubt, query the physician.
CDI:We did query the physician for Possible Pneumonia and this is what he stated in his DC summary:
“(4) Chronic lung disease
Assessment & Plan: Additionally he had a mildly productive cough and was initially started on Doxycline for a possible pneumonia. Sputum cultures grew pseudomonas and H. Flu so he was switched to IV cefepime. On discharge he will be given Ceftin 500mg BID for another 5 days.â€
CODER: Did the physician discontinue antibiotics after that time?
CDI: No, patient was sent home on Ceftin PO for possible pneumonia.
CODER:Was the patient getting respiratory treatments?
CDI:Yes, pt was receiving duoneb treatments QID and receiving anywhere from 2-5L O2 during the patients stay.
CODER:Was the patient put on Lasix or a similar medication?
CDI:Yes, 40mg Lasix Q24hrs.
CODER:Did the presenting symptoms lessen after they received that medication?
CDI: Yes, with diureses, antibiotics and nebulizers his oxygen requirements improved. Patient was giving the 2 different antibiotics while in the hospital (Doxycycline and Amoxicillin) and sent home with a PO antibiotic for possible pneumonia.
The sputum culture also came back positive with Haemophilus Influenzae
Thank you for your help
Jessica Stevenson, RN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
871-2396
CODER: If a physician (especially if it’s a specialist in the condition being evaluated) notes that an earlier suspected condition is ruled out and there is no other documentation that contradicts that statement, you are pretty safe in assuming that the patient did not have pneumonia. If in doubt, query the physician.
CDI:We did query the physician for Possible Pneumonia and this is what he stated in his DC summary:
“(4) Chronic lung disease
Assessment & Plan: Additionally he had a mildly productive cough and was initially started on Doxycline for a possible pneumonia. Sputum cultures grew pseudomonas and H. Flu so he was switched to IV cefepime. On discharge he will be given Ceftin 500mg BID for another 5 days.â€
CODER: Did the physician discontinue antibiotics after that time?
CDI: No, patient was sent home on Ceftin PO for possible pneumonia.
CODER:Was the patient getting respiratory treatments?
CDI:Yes, pt was receiving duoneb treatments QID and receiving anywhere from 2-5L O2 during the patients stay.
CODER:Was the patient put on Lasix or a similar medication?
CDI:Yes, 40mg Lasix Q24hrs.
CODER:Did the presenting symptoms lessen after they received that medication?
CDI: Yes, with diureses, antibiotics and nebulizers his oxygen requirements improved. Patient was giving the 2 different antibiotics while in the hospital (Doxycycline and Amoxicillin) and sent home with a PO antibiotic for possible pneumonia.
The sputum culture also came back positive with Haemophilus Influenzae
Thank you for your help
Jessica Stevenson, RN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
871-2396
Comments
H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
sb
"DC summary:
“(4) Chronic lung disease
Assessment & Plan: Additionally he had a mildly productive cough and was initially started on Doxycline for a possible pneumonia. Sputum cultures grew pseudomonas and H. Flu so he was switched to IV cefepime. On discharge he will be given Ceftin 500mg BID for another 5 days.”
Seems to indicate this info is in dc summary... Is there a conflict in the dc summary. Treatment is given seems totally clear PNA should be coded.
I don't get the info on Lasix and respiratory tx? Not needed for PNA ...
Could you query for pseudomonas PNA? Increases specificity/RW?
Agree that there does seem to be a potential opportunity to specify the pna type being treated as documentation of a positive sputum culture alone is not enough to establish a link.
Kerry Seekircher, RN, BS, CCDS, CDIP
Claudine Hutchinson RN (CDI)