What's wrong with aspiration pneumonia?

The coding around it is a dumpster fire.

ICD-10 is confusing. What else is new… but it’s a problem when it’s considered a hospital complication by quality platforms that are used to grade you and your hospital.

(There are some reading this who know way more about quality than I do. There are some that this is a foreign language for. I’ll keep it simple)

What do I mean?

First, when doctors document “aspiration pneumonia” and “aspiration pneumonitis” we mean two very different processes.

Aspiration pneumonia is an infection caused by the aspiration of oropharyngeal or gastric contents. We will give antibiotics to treat this and typically has a slower course of improvement similar to other pneumonias.

Aspiration pneumonitis is inflammation of the airways caused by aspiration of oropharyngeal or gastric contents. This does NOT always lead to infection of the lung parenchyma. This is typically characterized by a SUDDEN clinical change including dyspnea, wheezing and possibly hypoxia. Most physicians will treat with antibiotics empirically for pneumonia. However, patients will typically then have a RAPID improvement (usually within 48 hours) - especially for the degree of their hypoxia.

The problem? There is NO differentiation between these two in ICD10. They both code to J69 Pneumonitis due to inhalation of food and vomit. (Clinicians, don’t stop reading now! There’s a clinical impact to all of this…)

When I discovered this issue, I went to UpToDate for answers.

Though the above definitions are how I was trained and EVERY doctor I’ve spoken to on this subject agrees, UpToDate suggested “Chemical Pneumonitis” as a more accurate description for what we typically call “aspiration pneumonitis.”

Great! Problem solved?!

Nope.

That codes back to the exact same diagnosis…

So, if a patient only has aspiration pneumonitis, you could still get dinged for an in-hospital “aspiration pneumonia” because of coding. I don’t like that.

So, what to do?

For Physicians and Advance Practice Providers:

Continue to treat a significant aspiration event empirically with antibiotics as usual.

However, reassess daily. If the course is ultimately not consistent with a pneumonia and you feel comfortable stopping antibiotics, document “Aspiration pneumonia ruled out.” This removes it from coding.

Is this ONLY for coding and complication rate reasons? Nope.

Reconsider this diagnosis on a daily basis for the sake of antibiotic stewardship. All too often, antibiotics are continued for a full course without reconsideration of if pneumonia truly developed or not.

With that said, it would still be worth asking your manager / quality department if they consider this a hospital complication. Hospitals may use this, among other things, to produce a “report card” on you.

I’ve also noticed insurances love to deny payment when patients are admitted with “aspiration pneumonia” but have no fevers, leukocytosis, etc. This is less of an attack on the “aspiration” aspect but on the clinical validity of “pneumonia.” They likely go after aspiration pneumonia a bit harder as it is a complex pneumonia versus a simple pneumonia. Read more here:

For CDI professionals:

My coding department and I have nerded out on this pretty hard. I considered J680 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors. This belongs to DRG 205 - 206 “Other respiratory system diagnoses.” But these were generally external gaseous causes of the pneumonitis.

We followed the 3M coding pathway, and ended up in a poisoning DRG:

Pneumonitis → Chemical → Other → Gastric enzymes → T475X1A: Poisoning by digestants followed by J680 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors → DRG 918

So, that definitely isn’t it.

This is not a HAC or PSI but considered a hospital complication by at least one major quality platform (I can’t speak to others). It might be worth talking to your quality department to look into this as well.

Am I just mincing words and trying to “get around a complication?" No. The degree of complication matters. The precedent has been set by other complications. Is just a fall a complication? No, it’s a fall with a hip fracture. Is catheter associated inflammation a complication? No, it’s infection. So, the differentiation between pneumonitis and pneumonia is important.

The Coding Clinic Second Quarter 2019 “Aspiration bronchitis” came close to addressing my concern and does provide some additional context:

Just as we found, the term “aspiration” is quite important.

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

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

Cheers,

Robert

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