Too Query or not to query

dschrader71dschrader71
in Clinical & Coding

I am new to the CDI arena, currently trying to gain a grasp on the coding aspect and what exactly the coder needs.  My question is if a physician states in their plan and assessment

1.) Pneumonia. Blood cultures positive for Staph Aureus sensitive to ....................................... 

               or

 2.) Sepsis secondary to pneumonia. Gram positive bacteremia. 2 sets of blood cultures with gram-positive cocci

Do either or both of these need additional clarification to link the positive blood cultures to the pneumonia? 

I appreciate any and all feedback!!

Comments

  • bbogda@morrishospital.orgbbogda@morrishospital.org

    #1.  Yes, clarify.  Just because there is bacteremia does not mean that organism is the cause of the pneumonia.  Needs to be a link

    #2.  Yes, clarify. Same scenario.  Sepsis is secondary to pneumonia, pt has bacteremia, still need to link the pneumonia to the organism.  I know it seems logical that the pneumonia would be due to the same organism, but this it is not an assumed link (at least not in our facility).   

    Same with sputum cultures, if there is a positive sputum culture with a pneumonia, we still need to have the doctor make the link.  We can't assume.   

  • cindys@hollandhospital.orgcindys@hollandhospital.org
    agree need linkage of "due to, secondary to, etc"
  • dschrader71dschrader71
    bbogda@morrishospital.org said:

    #1.  Yes, clarify.  Just because there is bacteremia does not mean that organism is the cause of the pneumonia.  Needs to be a link

    #2.  Yes, clarify. Same scenario.  Sepsis is secondary to pneumonia, pt has bacteremia, still need to link the pneumonia to the organism.  I know it seems logical that the pneumonia would be due to the same organism, but this it is not an assumed link (at least not in our facility).   

    Same with sputum cultures, if there is a positive sputum culture with a pneumonia, we still need to have the doctor make the link.  We can't assume.   


    Thank you for your input
  • dschrader71dschrader71
    quincy said:
    agree need linkage of "due to, secondary to, etc"

    Thank you for your input!!
  • Sharme.Brodie@hcpro.comSharme.Brodie@hcpro.com
    We always want the patients medical record to be as accurate as possible. Remember the old saying about "Assuming"? well it applies to documentation in the medical record as well and can get us into trouble. So a good rule of thumb to follow would be anytime there is documentation of an infection whether it is localized or systemic our goal would be to have the organism identified and linked to the infection. this can be accomplish by educating the physician to document using  "cause and effect" language such as "due to" "related to" or secondary to" as in Pneumonia due to pseudomonas" or Sepsis related to E.coli.  It can also be demonstrated by the way a physician documents the diagnosis, such as "Pseudomonas pneumonia" or "E. Coli Sepsis". Bacteremia by definition denotes bacteria in their blood, it is considered an abnormal lab value and would require a query for clarification of its meaning- Is it contamination? or is it evidence of an infection?
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