Pneumonia

joan.rucker@va.govjoan.rucker@va.gov
in Clinical & Coding

Provider presented this question to me after reviewing a record. A patient is dx with aspiration pneumonia and pneumonia due to MRSA. Two codes are assigned by the coders according to the coding guidelines. However, the provider feel clinically these are not two different pneumonias, when a patient aspirates they can get MRSA pneumonia.

Your feedback would be appreciated.

Thanks

Joan E. Rucker

CMJ VAMC (Philadelphia)


Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Definitely 2 codes as aspiration is the mechanism and the MD has stated the aspiration resulted in a specific  infection.   Pneumonia can be stated and coded as ‘cause or mechnism’, such as Aspriation/VAP, as well as infective agent.  When the specific agent caused by the aspiration is stated, an additional code is used to fully describe the disease process.  (Based on my observations, aspiration pneumonia frequently results in a gram-negative anaerobic infection).  Be that as it may,  code both aspriation and MRSA type of pneumonia if both are documented.
    Paul Evans, RHIA, CCDS
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Also, note you stated ‘when a patient aspriaties, a patient CAN develop MRSA”.

     
    Since MRSA is not always present, and often, no additional type of infective agent is noted, and/or some other type of infective agent may be a consequence,  TWO codes are used to report the specifics of each case.
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