Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 2

by Shannon Newell, RHIA, CCS

Pneumonia as a principal diagnosis

Consider the following case studies.

Case study 3: A patient with history of chronic obstructive pulmonary disease (COPD) presents to the ER with complaints of a low-grade fever of 99.8, and shortness of breath for two days with intermittent minimal wheezing. Chest x-ray is positive for a left upper lobe infiltrate. The patient’s white blood cell count is 10,000, lactic acid is 0.8, pulse is 88, and respiratory rate is 22 breaths per minute with a pulse oxygen level of 96% on 2 liters. The patient is admitted with COPD exacerbation and community-acquired pneumonia. The patient is started on IV antibiotics for treatment of the community-acquired pneumonia and receives bronchodilators every four hours without IV Solu-Medrol for treatment of the COPD. The patient’s condition improves, and in four days the patient is discharged on oral antibiotics. Documented diagnoses: Community-acquired pneumonia and COPD exacerbation. Pneumonia, unspecified organism is coded as the principal diagnosis. Both pneumonia and COPD exacerbation are clinically supported as principal diagnosis options. ICD-10 classification instructions require that patients with COPD with acute lower respiratory infections have COPD sequenced as the principal diagnosis. The correct selection of COPD as the principal diagnosis with pneumonia as a reported secondary, POA diagnosis would exclude the discharge from the readmission and mortality outcome cohorts.

Sepsis as a principal diagnosis: The inclusion of pneumonia as a secondary, POA diagnosis does not include a discharge in the outcome cohorts. This rule of thumb is typically true: Only cases with a principal diagnosis of pneumonia will “count.” There is one exception, however, and that is the reporting of pneumonia as a secondary, POA diagnosis when sepsis is reported as the principal diagnosis.

If sepsis is reported as the principal diagnosis and pneumonia is reported as a secondary, POA diagnosis, the discharge will be included in both the readmission and mortality outcome cohorts. In such cases, if—in addition to the secondary diagnosis of pneumonia—severe sepsis is present and reported as a secondary, POA diagnosis, the discharge is excluded from the cohort.

The evidence-based definitions adopted for use will impact how sepsis/severe sepsis codes are reported and, in turn, will impact performance for the pneumonia mortality and readmission outcomes.

Case study using the Sepsis-2 definition

• Scenario:
  
  • A patient is admitted with pneumonia not elsewhere specified, with multiple clinical indicators of a systemic infection (temperature 102; respiratory rate 28 breaths per minute; white blood cell count 18,000 uL; pulse 120 beats per minute; lactic acid level 2.4 mmol/L).

The patient’s blood pressure, mental status, platelet count, bilirubin, and renal function are all within normal limits, and there is no evidence of delayed capillary refill.

• Principal diagnosis:
  
  • Sepsis—if documented—would be reported as the principal diagnosis. (If not documented, a query would be recommended given the multiple clinical indicators of a systemic infection.)
  • Pneumonia would be reported as a secondary, POA diagnosis.
• Pneumonia mortality/readmission cohorts:
  
  • The patient would be included in the cohorts.
  • An opportunity to exclude the discharge from the cohorts exists if Sepsis-2 criteria are used and severe sepsis is documented. (If not documented, a query would be recommended using the following clinical support: lactic acid level greater than the upper limits of laboratory normal (1 mmol/L).)

Case study using Sepsis-3 definition

• Scenario:
  
  • Same as case study with the Sepsis-2 definition above.
• Principal diagnosis:
  
  • If the Sepsis-3 definition is used, the clinical indicators in this patient do not meet sepsis definition requirements. This is because the elevated lactic acid level is not part of the Sequential Organ Failure Assessment score defining sepsis.
  • The principal diagnosis would be pneumonia. Sepsis and severe sepsis would not be reported.
• Pneumonia mortality/readmission cohorts:
  
  • The patient would be included in the cohorts.

Discharge status of “against medical advice”

Whenever “against medical advice” is reported as the discharge status, that discharge is excluded from both the mortality and readmission cohorts. CDI teams typically focus on accuracy of discharge status due to its impact on accurate MS-DRG assignment and payments.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. To read the first part of this article, click here. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.