Q&A: Exploring HCAP, A Physician Documentation Dilemma

Q: If the physician documents “HCAP” is that sufficient to be able to code a gram negative and/or pneumonia?

A: If the physician documents “HCAP” the code defaults to 486, unspecified pneumonia. When this is the principal diagnosis, it results in DRG 193-195, simple pneumonia. Documentation of suspected/likely/etc. gram negative pneumonia, or organisms, results in code 482.83, other gram negative pneumonia. This is assigned to DRG 177-179, respiratory infections.

Q: Can you please clarify whether or not HCAP and CAP can be used for coding purposes, and if we should query for the specific organism?

A: In both ICD-9 and ICD-10 classifications, HCAP and CAP default to code 486, unspecified pneumonia, and therefore DRG 193-195, simple pneumonia, is assigned if it is the principal diagnosis. CAP belongs in DRG 193-195, and therefore does not require further specification of causative organism for a clinically correct DRG assignment. HCAP represents a much more complex, severe type of pneumonia caused primarily by staph and gram negative organisms, most appropriately described by DRG 177-179, respiratory infections. The most probable/suspected/likely organism(s) causing HCAP must be documented to allow correct coding to these DRGs.

Q: Is there any coding guideline that states you must have a positive sputum culture to code gram negative PNA, even when documented by a physician?

A: No, although in that case one would expect the diagnosis to be qualified with some term expressing the degree of certainty such as probable, suspected, likely, etc. Code assignment is based on consideration of all the documentation and information contained in the medical record taken in its full context and the “clinical validity” of documented diagnoses, meaning the findings are consistent with medical professional diagnostic and treatment standards and/or evidence-based medical literature.

Q: When the physician does not mention the organism in the final impression, can we consider the labs, or does the physician have to document it in the final impression?

A: Culture results alone cannot be used for code assignment. The documentation of the probable/suspected organism(s) is not required in the discharge diagnoses if documented elsewhere in the record, is clinically consistent with the diagnosis, if there is no evidence that the probable/suspected cause has changed “at the time of discharge,” and it was treated with a full course of indicated antibiotics for staph and/or gram negatives.

Editor’s Note: Richard D. Pinson, MD, FACP, CCS, co-founder and Principal of HCQ Consulting, answered these questions, as part of a supplement to our July 9, 2015 webinar, “Exploring HCAP: A Physician Documentation Dilemma.” For more information and access to a complete version of this Q&A, click here.