Q&A: Podcast recap, community acquired pneumonia clinical and coding updates (part 2)

Q: I am wondering about new rules related to community-acquired pneumonia clinical guidelines?

A: There was a consensus article put out by the American Thoracic Society a couple of years ago that had two major impacts. The first term HCAP or healthcare-acquired pneumonia is now, RIP. Rest in peace. The term is dead. So, we're done with that. That descriptor would have described healthcare-acquired pneumonia in patients who are in nursing homes, or conjugate living facilities, or chemotherapy units, or dialysis units, those pneumonia patients were felt to represent gram-negative and staphylococcus pneumonias.

But after many years of treating these patients with aggressive antibiotics, we realized we weren't doing any good. We weren't reducing hospitalizations, length of stay, death rates, anything. Now, we realize, unless there are certain risk factors present, we don't consider patients coming from the healthcare setting to automatically have a gram-negative pneumonia. We still use the term hospital acquired but that is different from healthcare acquired.

Obviously, we know, for the clinical record it is critical to get the causative organism in there as it affects just about anything you want to mention related to downstream healthcare data, care, and reimbursement from MS-DRGs to hierarchical condition categories (HCCs), and associated quality outcomes—and of course, you need to be careful of some of the compliance risks that might surround this diagnosis.

Why is it such a big deal, other than the obvious medical impact for the patient? Most CDI professionals know that the term community-acquired pneumonia is a group of possible pneumonia types. When we say that term, we usually mean streptococcus, pneumococcus, viral pneumonia, atypical organisms like mycoplasma, Legionella klebsiella, etc. All those bugs map to a code for a simple pneumoniae DRG which has a lower weight, lower expected death rate, lower hospitalization stay than say, complex pneumonias.

When a doctor says “community-acquired pneumonia,” I automatically assume it's going to go to simple pneumonia DRG. That has an impact. And it’s not just DRG but HCC as well. So, if our gram-negatives move to the community-acquired pneumonia heading, our task now is to get CDI folks to help providers enumerate the bacteria which specifically caused the pneumonia rather than resorting to terms like community-acquired pneumonia, or healthcare-acquired, or hospital-acquired pneumonia. Because those conditions don't have a code. They actually map to pneumonia, not specified, which goes to simple pneumonia DRG.

It's always been important for us to document what we think the organism is, because patient treatment varies based on that. But it's even more important now to understand the outcomes related to DRG and HCC assignment and to be able to delineate that. 

It's not just our fault as physicians, clinically. We don't have great tools to diagnose the etiology of pneumonia.

Editor’s note: This article is a recap of the September 8, 2021 episode of the ACDIS Podcast: Talking CDI.  Visit our hcmarketplace.com to purchase an on-demand copy of his webinar Deep Breaths: Tools to Decipher Documentation & Reporting for Respiratory Failure/Insufficiency.