Q&A: Podcast recap, community acquired pneumonia clinical and coding updates

Less than 10% of participants in a recent ACDIS Podcast: Talking CDI poll indicated their CDI program captures the diagnosis of gram-negative pneumonia well. Their biggest obstacle? A lack of diagnosis specificity, according to nearly 70% of respondents. Other responses included:

• 14% cite lack of clinical support including those risk factors.
• 9%, capture this diagnosis, well
• 5%, other
• 4% cite payer denials

“That’s a problem that plagues coders,” said William E. Haik, MD, FACCP, CDIP, director of DRG Review Inc., a physician-directed hospital coding consulting service, in Fort Walton Beach, Florida. “A lot of physicians don't know the epidemiology, the epidemiological setting that the bacteria occur. And so, they don't use those specific diagnoses that will allow coders to assign the right code. Instead, physicians just say, ‘community acquired’ or ‘hospital acquired,’ et cetera. Since there’s no code for that, it can be a real problem.”

Haik, a founding member of the ACDIS Advisory Board, presented at the October 2021 conference (ACDIS members can view his slides here) and will be presenting a webinar  “Capturing CC/MCCs: 2022 CDI Updates for Clinical Indicators and Query Opportunities,” on February 2. He’s a board certified internal pulmonary and critical care medicine, served as chief of internal medicine, director of respiratory care services, and was the president of the Okaloosa County Medical Society.

Q: Could you provide a clinical overview of gram-positive and gram-negative pneumonias?

A: We're always talking about gram negative pneumonias, but we never talk about what a gram-positive pneumonia is. So, I'd like to address that, but before I do, let's just talk about what pneumonia is.

Basically, you have signs and symptoms that can be hyperthermia or elevated temperature and get the patient may exhibit chills, fever, confusion, greater incidence of sputum production. Typically, you will have a pulmonary finding and filtering an acute pulmonary infiltrate seen on chest x-ray or CT scan.

However, the infiltrates may not be present on the initial chest x-ray, particularly if the patient is dehydrated. No water, no infiltrates. Sometimes, on the initial chest x-ray, (or the actual testing may be done from an AP direction of the funnel not a lateral chest x-ray) and we can miss it. The infiltrates could be obscured by, say, interstitial lung disease, which is what shows up as white on the chest x-ray. Since pneumonia is white, it's hard to see white-on-white. Unless you repeat a chest a-ray a few days later, then you might not see the infiltrate initially. And, according to the current treatment practices, we don't routinely repeat a chest x-ray in the hospital as long as the patient is improving. So, CDI professionals and coders need to look for that positive chest x-ray but they also have to be aware of other indicators such as the signs and symptoms already mentioned.

As far as distinguishing between what is a gram-positive and gram-negative pneumonia, the test is a gram stain, basically. It's just a stain we put on that helps us get a preliminary idea of the how the bacteria may grow out to be a culture. So, if it's gram-positive, that means it takes the stain with gram-negative meaning it doesn't pick up the stain. We look at the color and we look at the morphology. Is it caps on the ball shape or is it elongated like a rod?

Gram-positive bacteria includes your streptococcus. Gram-positive bacteria are very heterogeneous. However, we typically don’t use the term gram-positive in our clinical documentation. Gram-negative bacteria are very homogeneous. They typically are colonizers. These bacteria infect us in a different way. The pathogenesis are different and how we treat them is different.

Editor’s note: This article is a recap of the September 8, 2021 episode of the ACDIS Podcast: Talking CDI.  March 17 episode of the ACDIS Podcast: Talking CDI. Haik is a presenter at the ACDIS 2021 Annual Conference in Dallas, Texas, October 25-28. Visit our hcmarketplace.com to purchase an on-demand copy of his webinar Deep Breaths: Tools to Decipher Documentation & Reporting for Respiratory Failure/Insufficiency.