Query for Cause of PNA???

ggoodman@virginiahospitalcenter.com

Good Morning Everyone!

I have a question for the group regarding when to query for the
organism/cause of PNA.

The way I understand it, If the Doc writes Community Acquired PNA it
codes to simple PNA (DRG 193-195) and Aspiration PNA codes to complex
PNA (DRG 177-179). And I'm not sure what Hospital Acquired PNA codes to
(anyone know?).

My question is for coding and documentation purposes, if a doc writes
Community Acquired PNA or Hospital Acquired PNA, etc is that good enough
for documentation purposes or should I be querying these charts for a
specific organism?

Our CDI physician liaison has suggested that we try to get the Doc's to
always document the known/probable organism they are treating. I was
talking to a physician the other day about a patient who had CAP and
asked what organism they believed was responsible for the PNA. The Doc
stated that he didn't know and that it was very difficult to sometimes
determine what organism causes the PNA. He was not to thrilled with my
query. So I am curious as to when you all query for the PNA organism
and when you do not. My physician liaison mentioned that if a patient is
receiving Vancomycin the concern is for Staph Aureas, if the patient is
receiving Zosyn the concern is for Pseudomonas. Do you query based on
antibiotics given? I know that certain causes/organism if specified will
change a chart that may have been coded as a simple PNA to the Complex
PNA DRG. So, I just want to know when it is appropriate to query. Also
if you have any PNA cause/organism queries you would like to share that
would be appreciated!



Thank you!



Greta Goodman

Clinical Documentation Improvement Specialist

Health Information Management

Virginia Hospital Center

1701 North George Mason Drive

Arlington, VA 22205

703-558-5336

ggoodman@virginiahospitalcenter.com

robert.hodges2

Hospital vs. Community acquired all code the same, but hospital
acquired, as I'm sure you know, is one of the HAC's you won't get
reimbursed for from Medicare.



I always query for pneumonia type to help capture severity of illness
and risk of mortality. But when I query, I ask what kind of pneumonia
they suspect or that they are treating, especially if cultures are not
conclusive or are still pending. I won't ask for an organism usually,
but will wait to see if any cultures come back and will only query then
if they are positive and the provider doesn't link them back to the
pneumonia.



I'm attaching a copy of my query form in case you are interested.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



P: 989-497-2500 x13101

F: 989-321-4912

E: Robert.Hodges2@va.gov



"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley

lspryszak

Hi Robert:

Hospital-acquired pneumonia hasn't made it to the IPPS HAC list yet (although many think it should be).

Hospital acquired pneumonia is not included on the list for FY 2012 either.

Maybe you're thinking of AHRQ reporting?

robert.hodges2

I probably am. My oops.

Robert
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
 

lspryszak

I think it is always important to ask what the etiology of a disease is, across the board, because this approach reinforces one of our most basic CDI messages "what is the 'due to'"?

In ICD-9 we have some combination codes for organism-specific pneumonias but in ICD-10 we have a LOT more. If we start asking for the organism every time now, we'll be a lot further ahead once 10/1/13 arrives. Also, in ICD-10 there is one code set for "aspiration pneumonia due to anesthesia, fumes or gases" and another code set for
"pneumonia due to inhalation of blood, essences, food, oils, saliva, or solids and liquids" which is a little different than ICD-9.

So you can see that we will need even more information in ICD-10 -- not only the type of pneumonia, but the agent (foods, blood, etc.) as well.

The terms CAP and HAP came from treatment protocols and are not reflected in the available codes.

I recommend focusing on obtaining the specificity rather than the DRG assignment because if you get the etiology, the code assignment will take care of the DRG.

paxneros

Also look at how the patient is being treated. What antibiotics have been started?

What condition is the patient? Are there chronic diseases? NH patient? Hx of Stroke? Cancer w/Chemtx? Disabilities? ESRD?

Some of these may be clues as to what type of Pneumonia you may query for - Simple vs. Complex.

VAP, HAP, and CAP will all code to the same code 486, Simple Pneumonia, NOS. Often physicians are talking about specific Pneumonias (MRSA) and do not realize that due to verbiage these conditions will code to a lesser type of Pneumonia.

I'm like Robert-I usually query for type on anyone admitted for PNA because I want them thinking about being more specific regarding type. But I try to look at the entire picture and query according to what I am seeing.

NBrunson, RHIA, CCDS

catladyrn

I don't query specifically based on the antibiotics, but I definitely look at what abx are ordered and what organisms they usually target. Unfortunately for our purposes, many of them are broad-spectrum designed to hit a wide swath of bugs, and at the same time, I rarely see sputum cultures sent (especially prior to starting abx). But if it's a gram-negative specific antibiotic, and only if the clinical picture also supports a dx of possible gm-negative PNA, then I'll ask for it. I am averse to going fishing.

Someone posted a really nice PNA documentation decision tree in here a while back which I printed out, and keep in my handy-dandy resource notebook. Wish I could remember the author, but maybe they'll see this and post it again.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

sharon.cole

Renee,
I made some changes to the one that was posted on here, but this is similar.

paxneros

I wouldn't query based on Antibiotics either. However if a bed bound NH patient with a hx of stroke is admitted with a fever and a RLL Infiltrate and is placed on Clindamycin,I may include Aspiration Pneumonia as one of the choices on my query.

Unknown

Thanks Renee...I posted a documentation decision tree that is now in the tools library. I've attached it here also if anyone is interested.