What should you call that pneumonia?

Many people are still using CAP and HCAP for pneumonias.

This is why you shouldn't:

The problem?

• CAP & HCAP are meaningless in coding
• You’re documenting simple PNA's but treating complex PNA's therefore not getting credit
• Complex PNA's have higher reimbursement & risk of mortality
(PNA = Pneumonia)

Let's dig in.

1 / CAUSATIVE ORGANISM GUIDES CODING

This is important for several reasons:

1. Cultures are NOT required for causative organisms.

We all know sputum cultures are unreliable. Which leads to the next point...

2. A SUSPECTED organism can be based on RISK FACTORS. 

You do not have to PROVE an organism with cultures. It can be presumed based on risk factors. How often do you actually have culture data for pneumonias? Almost never. Therefore, determine a patient's risk factors and treat (and name) the pneumonia which the patient is likely to have based on those factors. (more on risk factors later)

Ex: Pneumonia due to suspected gram-negative bacteria.

Unclear diagnosis can be specified with "uncertain" verbiage (more in the Q/A below).

Many respond to queries with "I just don't know for SURE what the organism was." Not everything needs perfect objective data. Use clinical reasoning with risk factors.

3. If you DO have a positive culture or gram stain, you must LINK these two in your documentation.

Nothing can be assumed from a coder / CDI. Plus, many times we don't believe an organism growing on sputum culture is the actual causative organism.

If pseudomonas is growing on sputum culture, then specify, "Pneumonia due to Pseudomonas."

2 / WHAT IS SIMPLE PNEUMONIA?

Treating someone the hospital for "pneumonia" is "simple pneumonia" in coding language. A simple pneumonia doesn't (typically) need treatment in a hospital. What does that mean? It means you're likely treating mostly complex pneumonias.

More terms than you realize code to simple pneumonia:

• Healthcare Associated

• Community Acquired

• Nosocomial

• Post Obstructive

• Nursing Home Acquired

• Bilateral Pneumonia

• Bacterial Pneumonia

• Haemophilus pneumonia

• Viral Pneumonia

• Atypical

• Mycoplasma

• Streptococcal

Yep. CAP and HCAP mean the same thing.

So, what’s NOT simple Pneumonia?

3 / WHAT IS COMPLEX PNEUMONIA?

Again, coding is based on organism. So, as you can see above, the "location" based terms (community vs hospital) all default to simple pneumonias. The table below are all organisms which code to "complex pneumonias."

Getting away from location-based categorizing was supported by the 2019 ATS/IDSA guideline on pneumonias.

• Gram Negative

• Staph aureus

• Legionella

• Fungal

• Parasitic

• Aspiration

• Tuberculosis

• CMV, Varicella

• COVID

(Not an exhaustive list)

4 / MORE ON GRAM NEGATIVE PNEUMONIAS

So, since you can diagnose a suspected organism based on risk factors, what are Gram-Negative risk factors?

1. Hospitalized AND received IV antibiotics in the last 90 days (similar to the old definition of "HCAP" but with the caveat of having received IV antibiotics)

2. Immunosuppressed / Immunocompromised

3. Structural Lung Disease (bronchiectasis, Cystic Fibrosis, etc)

The Immunocompromised risk factors is a longer list than you would suspect. So, this is your "low hanging fruit" of gram negative, and therefore, complex pneumonias:

• Diabetes

• CKD

• Alcoholism

• Congestive Heart Failure

• Cirrhosis

• Advanced Cancer

• Chronic Prednisone >7.5mg / day

• Chemotherapy

• Organ Transplant Patients on immunosupression

• Asplenia (remember sickle cell...)

• Auto-immune disorders

• Chronic malnutrition

• Myeloproliferative / myelodysplastic disorders

• Drug-Induced Neutropenia

But insurance companies look to make sure if you SUSPECTED a gram-negative organism, that you also TREATED for it. They expect you to treat a gram-negative pneumonia empirically for at least 5 days. They consider gram negative antibiotics as:

• Zosyn

• Levofloxacin

• Ciprofloxacin

• Cefepime

• Ceftazadime

• Meropenem

• Ertapenem

• Tobramycin

• Gentamycin

• Amikacin

• Aztreonam

I know that list makes infectious disease doctors cringe.

However, if you have a CULTURE that proves a gram-negative organism and sensitivities suggest you can de-escalate to another antibiotic, then that is okay.

So, you need:

1. A risk factor.
2. Appropriate empiric antibiotics for 5 days
3. Unless you have a cultured organism.

Ideally, specify the risk factor(s) in your A/P:

Ex: "Pneumonia due to suspected gram-negative bacteria."
- Immunocompromised due to metastatic colon cancer on active chemotherapy

But don't do this stuff only for coding... do it because you think it's clinically necessary. BUT more people are at risk of complex pneumonias than you probably realized...and you can slightly change your documentation to get the credit you deserve

In Summary:
1. Coding is based on the causative organism of pneumonia (NOT location contracted)
2. The organism can be suspected by risk factors (without culture)
3. Hospitalized patients likely have "complex pneumonias"
4. Understand risk factors for Gram Negative Pneumonias.



Question / Answer

What is "uncertain" verbiage?
- You can use diagnosis of uncertainty in the inpatient setting as long as that diagnosis "has not been excluded at the time of discharge." Uncertain words include
• Likely
• Possible
• Probable
• Suspected
• Questionable
• Consistent with
• Compatible with
• Still to be ruled out

My hospital is enrolled in the BPCI Medicare Program which includes the "Simple Pneumonia and respiratory infections" inpatient anchor episode. Is that really just simple pneumonias?
- No. Whoever named that must have been unaware of the naming schemes. This does include complex pneumonias and does result in a higher reimbursement versus simple pneumonias, though not by much.

Based on the info above, I've probably treated a lot of complex pneumonias with Rocephin / azithromycin that got better. Are you saying I should start using Zosyn with those patients instead?
- As mentioned above, don't do these things only for coding. Do them if you feel they are clinically necessary. However, levofloxacin is an accepted treatment of "community acquired pneumonia" [cringe] but also an accepted gram-negative antibiotic. If clinically appropriate, you could consider using this antibiotic instead, given no contraindications, and still get credit for the gram-negative pneumonia - assuming no positive culture data with a gram-negative bacterium suggesting sensitivity to Rocephin.

Does someone's diabetes have to be very uncontrolled to qualify as immunocompromised?
- This is not black and white. Most physicians would likely agree at the very least the patient's diabetes should not be at goal to qualify as immunocompromised. The same for CKD - likely needs to be at least CKD Stage III. Also, there is no clear guidance for congestive heart failure with HFpEF vs HFrEF.

We use a Biofire platform for diagnostic BAL testing which often gives us positive results when the culture is negative. Do you think this fits the bill?
- At the end of the day, it's all about what insurances are willing to accept and what clinicians are deeming as reliable. I am not personally familiar with this testing, but if you think it is reliable and are making clinical decisions based off of it, then I would go with it. I would suspect if the insurance denied that claim, it would be easily defendable.

That’s all for now. I hope that’s helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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