Navigating pneumonia documentation

Navigating pneumonia documentation

Original author: Kathryn Fallah

Edited by: Jie Zheng, CCDIS

This article has been adapted from the Association of Clinical Documentation Integrity Specialists (ACDIS) It is posted here with their permission. The information in this article was originally derived from a PROPEL CDI presentation. Fallah is a PROPEL CDI member liaison. Click here to view the original article on the ACDIS blog.

Doctor looking at x-ray.

According to the World Health Organization, pneumonia is a form of an acute respiratory infection that inflames the lungs. When CDI professionals review the record and ensure the documentation of pneumonia is accurate and complete, their work can impact funding, risk-of-mortality scores, and risk adjustment. There are multiple types of pneumonia and etiologies, so CDI specialists must know how to identify and code each one.

To prove pneumonia is present, the physician writes a physical assessment and then requests a chest x-ray in an attempt to confirm pneumonia with imaging. In some cases, the chest x-ray may be negative and other diagnostics confirm the patient’s pneumonia. Sometimes, the clinical indicators may not be present on admission (POA). If a patient is admitted with another more acute issue, it could take a couple of days for their pneumonia to be diagnosed. In this situation, to support that diagnosis, a CDI specialist must study the symptoms a patient presents upon arrival—for example, are there complaints of fever, lethargy, or shortness of breath?

When a CDI specialist sees the chart of a patient with a pneumonia diagnosis, that’s where their
critical thinking must kick in.
– Kathryn Fallah

To assign an accurate code when pneumonia is documented, the CDI specialist must ensure the documentation specifies the type and etiology. Identification of the organism is key to determining the type of pneumonia present. This detailed information then influences the specific code and CMG+ assigned, which then impacts the patient’s risk-of-mortality score and risk adjustment.

Cases of pneumonia can be either simple or complex, and assessing the type is necessary for accurate treatment and reimbursement. It’s rare that a case of simple pneumonia requires a hospital stay, but hospital admission is necessary for complex cases since they require multiple combination antibiotics and can involve more multi-resistant organisms. With complex cases of pneumonia, symptoms to look out for include: exaggerated systemic inflammatory response syndrome (SIRS) and high fever, an elevated white cell count, increased sputum production and worsening respiratory status. A patient’s history should also be taken into consideration, including where the patient has been, their presentation, and their response to antibiotics and treatment—all information that aids in differentiating between simple and complex cases.  

A patient can either develop pneumonia inside the hospital, which is called hospital-acquired pneumonia (HAP) or outside the hospital, which is called community-acquired pneumonia (CAP). The vast majority of CAP diagnoses (roughly 85%) are due to three pathogens:

  • S. pneumoniae
  • H. influenzae
  • M. catarrhalis

Regardless of whether the pneumonia was CAP or HAP, CDI professionals should query the physician to determine the pathogen causing the condition. Without knowing the underlying organism, a CDI specialist cannot determine the CMG+.

If an associated organism is identified by the sputum culture, the organism can be linked to the disease process to confirm pneumonia. However, sputum cultures can be inconclusive and are often not clinically necessary. Ultimately, a physician can empirically diagnose pneumonia through patient assessment, risk factors, clinical findings, and response to treatment.

When a CDI specialist sees the chart of a patient with a pneumonia diagnosis, that’s where their critical thinking must kick in—a variety of defining questions must be considered to determine the right type and code. For example: Is a particular case clinically pneumonia, despite a negative chest x-ray? Has a causative organism or class been confirmed? Is pneumonia related to chronic lung disease, such as chronic obstructive pulmonary disease? To determine correct code assignment for accurate funding and quality reporting, these are the things CDI specialists must consider with every pneumonia course. Essential, too, is for the CDI professional to record in the query their evidence and findings.

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