Guest Post: Pneumonia coding compliance critical for success

by James S. Kennedy, MD, CCS, CDIP

In ascertaining pneumonia’s clinical validity, I like the criteria established by a work group of physicians convened by the Maryland Hospital Association that support compliant coding. Essential elements to diagnose pneumonia include one of each of the following three elements:

• Temperature > 38°C or < 36°C and/or leukopenia (<4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3)
• Purulent sputum, cough, dyspnea, tachypnea, supportive findings through physical exam (e.g. bronchial breath sounds, dullness to percussion), and/or worsening gas exchange
• Supportive imaging

There are many others, such as those from the Annals in Internal Medicine in 2003. These authors state that a negative chest x-ray is an imperfect gold standard in ruling out pneumonia, thus when a physician documents pneumonia with a negative chest x-ray, we must ascertain its clinical validity. If a provider maintains that a patient has pneumonia, especially when it is documented with uncertainty at the time of an inpatient discharge or in response to a clinical validation query, then we are on solid ground to code the condition. Coding Clinic, Fourth Quarter, 2016, page 149, is a valid defense of this principle.

Even though ICD-10-CM classifies pneumonia by its causative organism, querying for the underlying cause is tricky. The AHIMA Standards of Ethical Coding state that coding professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query, and cites that querying for gram-negative pneumonia on every pneumonia case regardless of clinical indicators is an example of unethical coding. Therefore, coders and their compliance personnel must know the clinical indicators supporting a query for the underlying cause of pneumonia as to target them appropriately and judge the validity of the documented response.

In my opinion, the best article addressing this dilemma is the 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society on hospital-acquired and ventilator-associated pneumonia.

In my reading, if a patient requires more than 2–3 days of an antibiotic other than ceftriaxone (Rocephin®), levofloxacin (Levaquin®) at 250–500 milligrams per day, azithromycin (Zithromax®), or similar agents, depending on the agent used that’s described in this article, the provider can support at the time of discharge that the pneumonia was likely due to the associated organism with hospital-acquired or ventilator-associated pneumonia. These include:

• Staph aureus – vancomycin or linezolid
• Pseudomonas – ciprofloxacin, levofloxacin (750 mg/day, not lower doses of 250–500 mg/day), aminoglycosides (gentamicin) or colistin – pseudomonas
• Other gram-negatives – Zosyn®, cefepime, imipenem, or azotrenam

Community-acquired pneumonia is a challenge, given that we often do not know what the causative organism is or that it is often viral in nature. Many physicians will still treat with an antibiotic, even though a study in the New England Journal of Medicine demonstrated an organism in only half of the cases studied and bacterial agent in only one out of seven hospitalized cases.

IDSA also published a guideline for community-acquired pneumonia which has a table of what antibiotics should be used in special circumstances. Options that influence DRG or HCC assignment include:

• Anaerobes (aspiration pneumonia) – Zosyn®, Unasyn®, or clindamycin
• Influenza – oseltamivir or zanamivir

Whether to query the physician for the bacteria justifying the use of Rocephin®, Zithromax®, or Levaquin® is an issue that will challenge all of us, especially if we’re working to manage our HCC-related risk-adjustment factor score. I’m open to suggestions if you have strategies that work in your facilities.

One final reminder: inpatient pneumonia cases with sepsis on admission are counted in the CMS mortality and readmission measures cohorts. However, the same cases with a secondary diagnosis of severe sepsis or sepsis with an associated organ dysfunction, are not. As we discussed in my previous sepsis columns, I hope that you’ve worked with your medical staff to define exactly what severe sepsis is and how to identify it at the time the inpatient order is written so that it may be properly documented and coded.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.