CAP vs HCAP and POA vs N-POA
I am have tried to explain the immune system cascade of events that occur in trying to help non-clinical coders to understand how on day 1 with minimal resp symptoms and no infiltrate on CXR, a patient can have a full blown PNA on day 2 that now shows up on CXR - AND how this is actually a CAP as opposed to an HCAP.
If they accept that, we will often have difficulty with the POA or not POA issue. How do you best get this information across and if you do, is that CAP POA or not POA? .
If they accept that, we will often have difficulty with the POA or not POA issue. How do you best get this information across and if you do, is that CAP POA or not POA? .
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According to CMS there is no limitation on the time period during the admission of when the provider identifies or documents that a condition was present on admission. However, its crucial the providers documentation demonstrates signs/symptoms and may be using words such as possible or suspected PNE can help with the confusion if the condition was POA or not when providers documentation demonstrates the definitive diagnosis.
If the patient is initially dehydrated the CXR will not demonstrate for one to two days. My question is: does documentation by the provider indicate dehydration with hydration of a bolus or any type IV infusion maintenance? If so, this will hopefully help with avoiding any confusion if the condition was POA or not.
If there is no CXR to confirm the diagnosis of PNA is the providers' documentation referencing to the clinical reasoning without the CXR?
To answer your question if the Coding staff can accept your explanation of the infection process it should be easy; however, does the providers' documentation support the POA? If yes, there should be no problem with the Coding staff to select "YES" as to POA.
Have you also explained the rule of thumb with HAC definition?
Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 hours after being admitted.
My final thought is this: it does not matter non-clinical or clinical there are guidelines and criteria we must follow to make sure the data is captured correctly. Teaching the definitions and reasoning of "why" helps. Tip cards are the best teaching tool to provide and open door policy with these types of issues.
Tenille Secrest, RHIT
Clinical Documentation Specialist
tsecrest@noch.org
Excellent response, citing great logic and 'clinical knowledge'. I'd not assume professional coders do 'not' have an abundance of clinical knowledge that at least some of us can use to excel in CDI.
P. Evans, RHIA, CCDS
I agree with you, Paul. Professional coders do have clinical knowledge. I am CDI who used to be IP coder with back ground of medical scribe for ED providers. What helped me land my job was my skill set of clinical knowledge and understanding of coding fundamentals and ect...
Tenille Secrest, RHIT
Precisely. Same here, and I wish this truth were better understood by some. That is all I wish to say now in this forum, and my formal views are a matter of record.
Paul Evans, RHIA, CCDS, CCS, CCS-P
Thank you so much for your responses. It is hard to imagine in 2018 but I have new employment in a system that has never had exposure to CDI prior to my arrival. As with all things new, change is a great idea - for those who thought it up! For others, it is often a bit less easy to acclimate to the change. Our real problems lay in the fact that funds for formal training are not currently available, so introducing these new ideas falls to me. I am in the habit of always supporting what I do with Coding Clinic as well as medical & nursing literature. When that fails, I am at a loss. Your words, as an authoritative CDI person (who is not me) will go a long way in helping them know that it is unbiased & factual.
For the record, I am an RN doing CDI for 13 yrs. I have learned a wealth of information from non-clinical Coders who can run circles around me in terms of CDI, and I have worked with those who were really good Coders but unfamiliar with principles of CDI, its purposes & multi-factorial benefits.
I apologize if my initial question was offensive to you. I assure you it was not intended that way.
Thank you for your input. It is greatly appreciated.
SBurke
Thank you for your thoughtful response, but no need for any apology and no offense taken on my part. I was trying to express my frustration around parts of this issue, and just did not want to 'stir' that conversation again via this forum. I understand your point of view, and I do agree there is much range of clinical knowledge among coders...ranging from little to none to very informed with formal education.
I am accustomed to working with and employing RHITs and RHIAs that satisfy the ACDIS requirements to sit for the CCDS exam. So, I expect professional coders to have a command of pertinent clinical topics. I concur that some coders may not succeed with the domain of the CDI profession, but others may excel.
Sincerely,
Paul Evans, RHIA, CCDS, CCS, CCS-P
Be aware that POA really has noting to do with the determination of CAP vs HCAP.
A patient can be admitted with CAP present on admission. They can also be admitted with HCAP present on admission. If they had a recent episode of care, they can even be admitted with HAP already present on admission. All three will be reported as simple pneumonia in the ICD 10 codes without further clarification.
On the flip side many of the organisms which will group to a simple pneumonia can be acquired within a hospital and be POA of no (such as Strep)
For this reason, it is more important to get the physicians regarding the specific type of organism or even the specific organism with regards to the situations evidence (location and clinical presentation) clinical severity (level of SIRS and resp compromise) and the therapeutic evidence (which treatments had to be instituted before effective therapy was established).
Also not the presence of absence of a positive chest x ray on admission also has little to do with the clinical truth of whether the pneumonia was truly present on admission. As stated above, there are a number of reasons why you can get a false negative chest x-ray within the first 24 hours, with being dehydrated probably among the most common.
Concur w/ above. Discussion of type of PNA aside, in regards to "POA" the following may be helpful.
Ref: 2018 ICD-10-CM Guidelines
There is no required timeframe as to when a provider (per the definition of "provider" used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider’s best clinical judgment