Q&A: Query for aspiration pneumonia

Q:  A physician admitted a patient with pneumonia, which was the first listed diagnosis. The second diagnosis was malnutrition secondary to feeding difficulties of the elderly. Two days later, the physician inserted a percutaneous gastrostomy tube. A day or two later, the physician documented only that the patient had aspirated. Our clinical documentation analyst queried the physician for aspiration pneumonia. The inpatient coders wanted your insight.

A: This may be on the cusp of leading, according to very conservative experts. Consider this query: “Please clarify whether there is a link between the patient’s pneumonia and the aspiration you described.”