"treated as gram negative pneumonia"
Pneumonia specificity is one of our top queries. Of course, the "probable, suspected, likely" can be documented but our providers would like to be able to document where they DONT get a query or have to follow to discharge summary. If they write "treated as aspiration pneumonia" or "treated as gram negative and gram positive pneumonia" and treatment, history, or clinical picture correlates do you code or query? Feel free to attached references
Thanks in advance!!
Breen Nabors RN
Clinical Documentation Improvement Educator
Fort Myers, Fl 33919
Substitute probable or suspected for “Treated as”
Question I would ask your providers:
If clinical evidence is pointing to aspiration or GNR Pneumonia and you are confident about your hypothesis, why wouldn’t you document the diagnosis as confirmed?
But if diagnostic uncertainty still exists because may be cultures were negative but the provider’s intuition points to the suspected diagnosis then the verbiage “probable” is better suited for the clinical scenario. Also note the “probable” comes from the probabilistic (Bayesian) reasoning approach used in the diagnostic process.
“Treated as” sounds like a conclusive diagnostic statement leaving out the uncertainty you get from using “probable”.
Also even with our vast clinical knowledge as documentation specialists, we cannot formulate diagnostic opinions or make assumptions about clinical indicators which it what your providers want you to do indirectly. We still have to ask the question (query).
According to Coding Clinic, "evidence of" is considered confirmed/established - not an uncertain diagnosis.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide