discussion: was this PNA POA or must it be coded as a HAP?

Hello all and thank you in advance for your time and expertise.  We have been involved in an academic discussion about a particularly odd case.  May I share some of it and ask for your input?
Nuts & bolts of the situation: chronic productive cough, green sputum occasionally hemoptysis, SOB, chills & night sweats - all indicating an infection but is afebrile with only  slight increased RR and elevated WBC.

CT shows Right sided emboli but also shows changes in the Left lung consistent with chronic bronchial and alveolar disease (bronchial wall thickening, mucus plugging and bronchial secretions on the L side + patchy bibasilar atelectasis).

Treated for emboli with ongoing cough, pleurisy, sputum and intermittent Sob, wheeze. Mounts a fever 102 on Day #2 with negative CXR, but WBC increases over following days with CXR showing haziness in left lower lung Day #5. Procalcitonin is negative as are blood cultures. Started on Levaquin and improves.

The chronic green sputum, cough and chills are not explained by acute PE. The abn CT lung is not explained either.

Conclusion: Most likely this is acute PE with chronic bronchiectasis and acute infective bronchitis. This is a hospital complication definitely but doubt that it is a pneumonia.

The discussion continued to include:

 - the inciting reasons for the 3rd chest x-ray were fatigue/tachycardia which are very nonspecific
 - So if a patient comes in with infective bacterial bronchitis which progresses to PNA during hospital admission, is that a hospital acquired PNA? I guess technically it is but the wording does not reflect the situation as it implies the patient picked up the infection in the hospital which this patient likely did not.
 - how long does it take from onset of symptoms to imaging findings in pneumonia typically on CXR? How soon does a PNA show on a CT scan vs CXR?   :  a Pulmonologist joins in with: CXR can lag by as much as 5 days depending on the fluid status and the technique (portable versus proper position versus penetration). The CT scan shows abn earlier but there hasn’t been a specific study of time course as far as I know. CT PE is not the best for PNA, and “ground glass” may be an alveolitis versus bronchiolitis versus early pneumonitis.
 - "This is a hospital complication definitely "...Is it?  It was POA!

Clearly there is an infection from the start (be it viral or bacterial). 
Bottom line question:  how do we code the presumed bacterial PNA that was treated after day 5?  It clearly was in evolution since before admission.

Can you help us sift through the details?
Many thanks-
Sue

Comments

  • Very dense question, and given it is Monday, brief response.  I don’t agree this is ‘definitely a hospital ‘complication’ - not at all.  As in, there were some s/s of infection that ‘could’ be attributed to a PNA that ‘after study’ was determined to have been ‘present on admission’. I would cite the signs, symptoms and support for the PNA, such as you have in your question, and issue a query for POA determination.
  • The present on admission guidelines actually answer this pretty well.  

    Conditions diagnosed during the admission but clearly present before admission Assign “Y” for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred. Diagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission. 

    https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf
  • Agree, if the signs and symptoms are clearly documented and clearly related to the diagnosis in question.  It is difficult to make that distinction in the scenario presented, but certainly correct to assign a POA of “Y” for a patient admitted with signs/symptoms of a condition that is confirmed some time after admission.
  • Agree, if the signs and symptoms are clearly documented and clearly related to the diagnosis in question.  It is difficult to make that distinction in the scenario presented, but certainly correct to assign a POA of “Y” for a patient admitted with signs/symptoms of a condition that is confirmed some time after admission.
    To summarize in a bit more concise way:
     Initial presentation had: chronic productive cough, green sputum occasionally hemoptysis, SOB, chills & night sweats

    24 hours in, cough, pleurisy, sputum and intermittent Sob, wheeze. Mounts a fever 102 

    Discussion: ...possible conclusion infective bacterial bronchitis which progresses to PNA during hospital admission.

    It is a judgement call for the doctor.   My personal feeling is the diagnosis was in evolution at the time of admission and thus, POA of Y.   Of course, we don't assign POA of Y for pressure injuries that progress during the stay so still a judgement call for the doctor I guess.

    I wouldn't mind seeing the BMP on that patient on admission to see if they were dry or not, as that could explain the delay in cxr findings, as could OP abx therapy.    

    I tend to look at POA of N as something reserved for completely new onset rather than evolving problems. 
  • Essentially, we agree.  But, the MD needs to ‘make the call’ the PNA was POA.  Hence,  I’d would issue a POA query for confirmation.    Judging by the comments and commentary, it seems this PNA may have been POA, but it is not clearly stated as such, and it is a given that a 3rd party would challenge the coding assignment.
  • Thank you both.  This was very helpful.
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