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A best practice is to always query for pneumonia specificity to avoid reporting J18.9.

In my last article, I wrote about the importance of reviewing Program for Evaluating Payment Patterns Electronic Report (PEPPER) data on a quarterly basis. In this article, I want to take a closer look at two coding target areas: simple pneumonia and respiratory infections. Pneumonia is one of those rare diagnoses for which documentation specificity impacts MS-DRG assignment. Not only can pneumonia specificity impact reimbursement through a MS-DRG shift, but it can also impact the medical necessity of the admission.

PEPPER data allows clinical documentation integrity (CDI) departments to compare the volume of cases involving simple pneumonia to those involving respiratory infections. Ideally, you want to have as few cases as possible in simple pneumonia, as it often doesn’t support the medical necessity of an inpatient admission.

Pneumonia and its symptoms can vary from mild to severe. Typically, a simple pneumonia case with a major complication or comorbidity (MCC) has evidence of complex pneumonia, because complex pneumonia is more likely to result in acute respiratory failure and sepsis. Of course, there can be comorbidities that lead to a CC or MCC within simple pneumonia, but usually, simple pneumonia can be treated in the outpatient setting – yet failed outpatient treatment can contribute to a pneumonia admission.

In addition to comorbidities, the causative organism or etiology affect the severity of pneumonia. Often, it is difficult for the provider to isolate the causative organism, but determining the etiology of pneumonia is often a clinical diagnosis, rather than a diagnostic one.

The diagnosis of pneumonia is typically suspected based on clinical presentation and an infiltrate on chest X-ray. In fact, even distinguishing between bacterial and viral pneumonia is difficult, due to a lack of conclusive diagnostic tests. In fact, “because of the limitations of current diagnostic tests and the success of empiric antibiotic treatment, experts recommend limiting attempts at microbiologic identification (e.g., cultures, specific antigen testing) unless patients are at high risk or have complications (e.g., severe pneumonia, immunocompromise, asplenia, failure to respond to empiric therapy),” as stated in a 2022 Merck Manual posting.

It is important to note that “empiric treatment” in this context does not mean that the patient doesn’t have pneumonia; it refers to the fact the provider is going to start with broad coverage and work their way to stronger, more targeted treatment if the patient does not improve. Due to this inability to accurately identify the causative organism, providers often classify pneumonia as community-acquired pneumonia (CAP) or hospital/healthcare-associated pneumonia (HAP/HCAP).

Strictly speaking, HAP is defined by the American Thoracic Society as a lung infection that begins in a non-intubated patient within 48 hours of admission, but it has more commonly been used interchangeably with HCAP to describe pneumonia associated with organisms that result from exposure to healthcare (e.g., nursing homes, dialysis, etc.) These are broad terms that allow the provider to differentiate a simple pneumonia, CAP, from a complex pneumonia (HAP/HCAP, e.g., one associated with a more virulent pathogen), but ICD-10-CM does not index using these terms, so they both default to J18.9, pneumonia, unspecified organism.

PEPPER data can help an organization determine if they have a high volume of cases reported with J18.9 pneumonia, unspecified organism, as these will appear in the volume of simple pneumonia cases. According to the Merck Manual, the most common pathogens associated with CAP are streptococcus pneumoniae, haemophilus influenzae, atypical bacteria (i.e., chlamydia pneumoniae, mycoplasma pneumoniae, legionella species), and viruses. Often, hospitals have CAP protocols and HAP/HCAP protocols.

Now, to make things more complicated, updated guidelines have clinically eliminated HCAP as a pneumonia classification tool, instead focusing on the severity of pneumonia. Why is this important? Because due to staffing, etc., some CDI departments only query for pneumonia specificity if HAP/HCAP is documented, since it can result in a DRG shift, but not when CAP is documented. A best practice is to always query for pneumonia specificity to avoid reporting J18.9.

Sign/symptom and ‘unspecified’ codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

As stated in the introductory section of these Official Coding Guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate ‘unspecified’ code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

ICD-10-CM Official Guidelines for Coding and Reporting

Typically, in the case of pneumonia, providers can use clinical findings to provide more specificity regarding the type of pneumonia. When it comes to associated pathogens, each hospital typically monitors the prevalence of different pathogens in its area to help determine appropriate antibiotic treatment.

As a CDI professional, it would be helpful to speak with your pharmacy team to find out what pathogens are typically targeted with each protocol so you can educate providers to be more specific in their documentation.

We know, as CDI professionals, that language is powerful. As I already mentioned, “empirical” can imply that pneumonia is not a substantiated diagnosis (e.g., that it is being prevented, but the provider is actually conveying they don’t know to which antibiotic the pathogen is sensitive, so they are starting with broad spectrum antibiotic). Often, the type of causative organism is a “ruling out” process, depending on the patient’s response to treatment. Coding Clinics discuss conflicting documentation, and that the attending physician’s documentation supersedes that of all other providers, but it wouldn’t be unusual for a provider to update their opinion during the course of hospitalization, so a query may be necessary to confirm the provider’s final conclusion of what type of pneumonia was treated during the admission.

Remember that the rule associated with uncertain diagnoses only applies in the inpatient setting and states, “if the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established.”

CDI professionals need to work with their coding departments so both are aligned on what documentation will result in assignment of a specified pneumonia code, rather than defaulting to J18.9, pneumonia, unspecified organism. Once decided, CDI staff will need to educate providers about how to best document the type of pneumonia with as much specificity as possible, understanding that this is a clinical diagnosis (e.g., that there will not be definitive diagnostic data to confirm their conclusion).

Many organizations find that it is acceptable for the provider to document “treating gram-negative pneumonia,” as most complex pneumonias are associated with a gram-negative organism, if it can’t be narrowed down further.

Moving cases into respiratory infections not only positively impacts reimbursement by shifting the case into higher-weighted MS-DRGs, but it also paints a more accurate clinical scenario. Improving pneumonia documentation takes collaboration with the coding department and educating providers.

Once providers consistently document pneumonia specificity, it should be reflected in PEPPER data. Over time, each organization should see a decrease in the volume of cases in simple pneumonia and an increase in cases in complex pneumonia.

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