I am struggling with the documentation of RSV bronchiolitis/pneumonia.  The physicians seem to use these two terms interchangeably on infants with RSV infections. One day they call it bronchiolitis, the next day pneumonia, or they write bronchiolitis/pneumonia. Do you query for clarification or code both?

A pediatrician told me that if they have bronchiolitis they also always have pneumonia?? That you can have pneumonia without bronchiolitis but if they have bronchiolitis they always have pneumonia??


  • my critical care docs only document the "superimposed bacterial pneumonia" when there is clinical or radiologic evidence of pneumonia.  If intubated we always collect a BAL which adds evidence as well.  Now if it is an older child >18-24 mos, they will usually refer to it as RSV pneumonia when they are very sick.  they firmly operate under the distinction of bronchiolitis being an infant/young toddler disease.
  • My coding department requests CDI to send a clarification if there is consistent vacillation between RSV bronchiolitis and RSV pneumonitis and RSV.
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