Q&A: Code assignment for hospital acquired/healthcare associated conditions

Q: Is it appropriate to assign code Y95, nosocomial condition, based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAC)? It is appropriate to assign code Y95, nosocomial condition, for documented healthcare associated conditions. Should this still be queried for specificity, and should the HAC condition (i.e. pneumonia) be coded as bacterial, viral, or something else?

 

A: When the provider uses terms such as “CAP,” “HAP,” or “HCAP,” these would default to code J18.9, pneumonia, unspecified organism, which maps to simple pneumonia MS-DRG 193/194/195.

 

Community acquired pneumonia (CAP) is typically a simple pneumonia, but could also be atypical pneumonia. Both hospital acquired pneumonia (HAP) and healthcare associated pneumonia (HCAP) can be considered nosocomial infections, and are most commonly caused by a gram negative organism.

 

Identification of the organism could move any of these from a simple pneumonia—MS-DRG 193, 194, or 195—to a complex pneumonia—MS-DRG 177, 178, or 179.  ICD-10-CM has numerous codes that link the causative organism and the pneumonia. Use of these codes is based on physician documentation linking the pneumonia and the causative organism.

 

Per AHA’s Coding Clinic, Third Quarter, 1994, we do not assign a code for bacterial pneumonia unless documentation in the medical record supports the presence of a bacteria.

 

If the physician identifies the pneumonia as a gram positive, mixed bacterial, or bacterial pneumonia without further specification, it would be coded to J15.9, unspecified bacterial pneumonia.

 

We always want to obtain the etiology of the pneumonia. As the MS-DRG assignment will vary based on etiology, this may require a query. The physician’s clinical opinion is sufficient to diagnose the type of infection. Diagnostic data, such as a positive sputum cultures or chest x-ray, are not necessary for the diagnosis.