Q&A: Querying to confirm pneumonia diagnoses

Q: A four-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?

A: Yes, the coder should query the provider for aspiration pneumonia: An infection that occurs when food, liquid, or vomit is breathed into the airways or lungs, instead of being swallowed. A chest-ray is used to confirm the presence of infiltrates in the lungs.

Confirming a diagnosis of aspiration pneumonia would change the ICD-10-CM code assignment, MS-DRG, geometric length of stay (GMLOS), relative weight, and reimbursement for diagnostic and procedural services.

For example, changing the diagnosis from simple pneumonia with pleurisy to aspiration pneumonia would:

• Allow for more specific ICD-10-CM code assignment (e.g., a code from category J69 [pneumonitis due to solids and liquids])
• Change the MS-DRG from 193 (Simple pneumonia and pleurisy with major complication or comorbidity [MCC]) to 177 (Respiratory infections and inflammations with MCC)
• Increase the GMLOS from 2.2 to 3.8 days
• Increase the relative weight and associated reimbursement by 67%

Editor’s note: This question was answered by Lucinda Lo, MD, a pediatric hospitalist at the Children’s Hospital of Philadelphia, during the HCPro webinar, “Pediatric Respiratory Conditions: Concerns for Documentation Integrity.”