Pneumonia and teaching to link 'possible' organism...my MD has ethical concern...please advise
How are each of you having the conversation/education (not the query itself) with your physicians related to encouraging more specificity with pneumonia and linking the organism when the cultures are not back?
I had encouraged that they are choosing an antibiotic with a presumption that it may be d/t certain organism. Eg. MD states “Atypical Pna” and treats the patient with with Levoflaxin…so therefore presumably could be thinking this patient may have a gram negative organism.
And therefore I teach them to link the ‘possible’ organism to the atypical pna, e.g. ‘Atypical Pna possibly d/t gram negative organism.” The physician’s ethical concern is that her diagnosis would skew the population health data in that when this is coded as “gram negative” type of pneumonia and possibly the culture results come back after discharge with a different type organism….that the coded data isn’t truly reflective of what the type of organism actually was.
Our focus is on specificity of diagnosis. We are a CAH hospital so this does not affect reimbursement, yet we do seek specificity for all of our diagnoses. I appreciated her concern and wondered how my peers are handling this concern. Thanks in advance for any feedback.
Comments
"The physician’s ethical concern is that her diagnosis would skew the population health data in that when this is coded as “gram negative” type of pneumonia and possibly the culture results come back after discharge with a different type organism….that the coded data isn’t truly reflective of what the type of organism actually was. "
Depending on how quickly the cultures are returned post-discharge you might try assuring the provider that the coders will verify the "suspected" diagnosis at time of coding. If a coder sees a negative lab result and a suspected diagnosis documented earlier in the chart they should be querying to confirm it before coding it. Without a query it's an easy target for a denial/recoupment later on as the lab results would effectively rule it out.
Erik Kilbo, CCS, CCS-P, CPC-I, CCDS, CDIP
I agree with the above.
A few other things.
The use of "possible" is discouraged from use in query forms circa the 2013 AHIMA practice brief on compliant query writing. No prohibited but discouraged.
The patient's history, physicial assessment and response to treatment ARE evidence based clinical indicators which are based in research and science.
Getting the exact sputum culture while admirable as a goal, is a nearly worthless goal in the real world. Sputum cultures are notoriously unreliable, difficult to get, and with results seriously questionable if there has been any antibiotic treatment prior to obtaining (which is almost always the case).
Frankly, relying on cultures has been mostly debunked as the ideal standard for practicing medicine in pneumonia patients. If you can get a culture great, you can use it for proper de-escalation and antibiotic selection.
However a negative culture is essentially meaningless. In fact, you may very well have had a legitimate organism which was gram negative and if treated with the correct antibiotics (either by luck or skill) then that late culture....even if appropriate technique was used, and even if the lab had the right culture media and the right temp and duration for incubation for that particular strain.... (and that is a lot of "ifs"..most of which I have little faith in), then you CAN STILL get a negative culture (even when everything went right).
Why? Well, when antibiotics are selected appropriately they do have this effect of actually killing the organisms (funny how that works right?...forgive the sarcasm).
In the real world, the clinically sound practitioner is going to look at what treatments failed, how severe or exacerbated is the SIRS response, the level of pulmonary compromise that was induced from this episode of illness, the color and nature of sputum, the patients immune status, what was the patients pre-existing pulmonary state, what type of facility did they come from (epidemiology), what is the patient's past history with pneumonia and organisms (if known) and what was their response to treatment in the current episode of care. To me, all of the aforementioned things are orders of magnitude better than a culture. There are of course, always exceptions. That is why they "practice" medicine and sorting through atypical cases is why they get paid the big bucks.
Your preferred documentation convention here is "evidence of"...and then state what that evidence was.
"Possible" is definitely not the best nomenclature.
Assuming that a full course of antibiotic therapy for gram negatives and/or staph is prescribed, it is essential that providers document the "most likely" or "suspected" organism (or using other terms of uncertainty) causing HCAP, based on this evidence-based medical literature, clinical practice and recommendations of the Infectious Disease Society of America (IDSA), to capture the severity if illness (high mortality) and high cost of care for HCAP patients.
Otherwise these patients will be classified as simple pneumonia like pneumococcal and mycoplasm having low severity of illness (low mortality) and much lower cost of care. Furthermore, quality metrics for the provider and hospital will be adversely affected.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com