December 18, 2019

Pneumonia: Take Key Steps to Protect Your Patient from a DRG Downgrade

Pneumonia is a commonly used term to describe an infection that causes the air sacs in the lungs to become inflamed. There are critical differences in the types and severity of pneumonia, which clinicians evaluate and treat accordingly. Because the term is generic, clinicians frequently code pneumonia in a way that misrepresents how sick a patient is. Pneumonia miscoding makes it vitally important to follow best practices for documentation with specific information describing the severity of the illness to support the correct DRG.

Commonly, providers use the following terminology to code “simple” pneumonia:

Incorrectly coding these severe conditions as “simple” pneumonia can adversely affect the severity of illness in the DRG.

However, under the coding guidelines, if a patient is receiving antibiotics for possible MRSA, MSSA, or gram-negative pneumonia, then their condition can be coded as possible, probable, or suspected MRSA, MSSA, or gram-negative pneumonia. When documented accordingly, the appropriate severity of illness will reflect in the DRG.

For example, a patient receiving treatment with vancomycin or Zyvox for possible MRSA pneumonia or with Zosyn for possible gram-negative pneumonia has an increased severity of illness. When properly documented, the DRG should reflect the severity of illness. In other words, you’re documenting how sick your patient is, appropriately and with specificity.

Clinicians also overlook aspiration pneumonia. Aspiration pneumonia is a complication of pulmonary aspiration when a patient inhales food, stomach acid, or saliva into the lungs. Patients can also aspirate food that travels back up from the stomach to the esophagus.

When a patient has gastrointestinal or neurological issues such as a stroke with dysphasia, clinicians should consider aspiration pneumonia. These conditions predispose patients to aspiration, which carries bacteria that affect the lungs.

To reflect the severity of a patient’s illness, clinicians should consider:

  • Is workup ongoing for this, such as speech therapy or a swallowing study?
  • Are there typical radiographic findings, such as a right lower lobe infiltrate?
  • Is the patient being treated with clindamycin, Flagyl, or another agent covering suspected aspiration-type organisms?

When it comes to pneumonia, remember:

  • Code diagnoses as if they exist, even if not proven, by stating phrases such as possible, probable, and likely.
  • Consider gram-negative pneumonia in patients with cancer, COPD, the elderly, or recent hospitalization.
  • Consider MSSA/MRSA in patients with ESRD, indwelling catheters, open wounds, post-op, and IVDA.

To accurately reflect the severity of the patient’s illness, clinicians’ words are powerful. The words used should paint a picture, supported by specifics, that captures how truly sick the patient is. Ultimately, in the documentation, a few words can have an enormous impact on protecting your patient from a DRG downgrade.

Dr. Wagstaff presented on this topic in the Sound Advisory Services webinar, Strategies to Combat Inappropriate DRG Downgrades. Click here to watch the webinar.

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