Q&A: Pneumonia in an HIV disease patient

Q: Is pneumonia in HIV disease patients always considered an HIV-related condition?

A: There are Official Guidelines for Coding and Reporting that must be adhered to when coding and reporting of HIV disease. If the documentation is not clear about the reason for the admission or whether the condition is related to the HIV disease, a query may be needed to clarify. I would review the Official Guidelines for Coding and Reporting, Section I.C.1.a., regarding how to code and sequence HIV disease. 

As CDI specialists, we need to make sure that the documentation in a patient’s medical record is clear and concisely written so that anyone reviewing the record would come to the same conclusion based on the documentation. It is a hard habit to break, but we need to be careful and not assume anything based on our education or past experience.

Although pneumonia occurs commonly in HIV-disease patients and remains an important cause of increased morbidity and mortality, we need to make sure the documentation clearly links the pneumonia to the HIV disease so the encounter is coded correctly.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.