Documentation of Aspiration Pneumonia

smilingso@aol.comsmilingso@aol.com
in Clinical & Coding

Our physician documented "Aspiration lung injury/PNA"   I asked our coder if this was adequate for DX of Aspiration Pneumonia. She said it was not. The Doctor must write out Aspiration Pneumonia.  Is this correct?  Christine Koehler

Comments

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    I found some old info we rec'd from a consultant and they quoted a coding clinic and stated "the physician must document and link the etiology of the pneumonia". It would probably be prudent to query just for confirmation.

    Jeff

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