Q&A: Capture clinical indicators in the medical record

Then, 23-48 hours into the stay, the radiologist interpreted a chest x-ray with possible infiltrates. Must the hospitalist or physician have a chest x-ray with infiltrates to confirm pneumonia? Or can he, after work- up, determine the patient has pneumonia without a positive chest x-ray or blood cultures?

 

Also, if the blood cultures are negative but based on his clinical judgment, can he state that he is treating a bacterial or viral pneumonia without supporting test results?

 

A: Neither CMS in its Conditions for Participation nor the Official Guidelines for Coding and Reporting requires a positive chest x-ray in order for the provider to diagnose pneumonia. The physician can make a diagnosis based on the patient’s medical history, epidemiology, response to treatment, etc. as patients are often diagnosed in the physician office with pneumonia without a confirmation x-ray.

 

It is assumed that the physician has the skill to make these types of diagnoses by virtue of being a physician. However, be aware that external auditors may challenge the diagnosis of pneumonia (or other conditions) if the medical record does not include supportive diagnostics. What I often advise is for the provider to document “evidence of pneumonia based on (the presenting symptoms, etc.).” 

 

As a matter of fact, most articles about healthcare associated pneumonia commonly referred to as HCAP discuss how the diagnosis is made through patient history such as dialysis patient, recent hospital admission, family of an ICU patient, etc.

 

Specifically addressing the scenario you describe above, I suggest determining if there was evidence of pneumonia at the time of admission. If not, the provider can state suspected pneumonia, but you would then want them to verify the pneumonia or state that pneumonia was ruled out within the progress notes and/or discharge summary. If the provider does not make the diagnosis until several days into the stay, make sure they clearly state the pneumonia was present on admission.

 

CMS quality metrics require the obtaining of blood cultures within hours of diagnosing pneumonia in the ED; however, blood cultures often fail to isolate the pathogen. When talking to physicians, I ask them to document not in terms of a blood culture being negative, rather to state “evidence of XYZ (based on presentation), blood culture unable to isolate pathogen.”

 

If you think about it, the blood culture isn’t negative as a pathogen is causing the pneumonia, it is just that the organism was not isolated in the culture. Conclusive diagnostics like blood cultures (and chest x-rays) are not required to make a diagnosis, but the diagnosis must be clearly supported by clinical indicators (e.g., patient reports difficulty breathing, decreased breath sounds on auscultation, productive cough, failed outpatient antibiotic treatment, pulse oxygen values, etc.).

 

Depending on your coding staff, if the provider states treating gram negative pneumonia to support the DRG of respiratory infections, but later states the blood culture is negative, many coders will only code pneumonia unspecified, moving the DRG back to simple pneumonia. Keep in mind that providers need to state they are “treating” XYZ not “covering” because when it comes time to assign a code for the care of the patient, the terms “treating” and “covering” are not synonymous. Also if the provider states “empirical” treatment the coder will often not code the diagnosis.

 

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.