Healthcare-Associated Pneumonia (HCAP), and Why You Should Not Diagnose It

By: Timothy Brundage, MD, CCDS, Medical Director & CEO of Brundage Group

The diagnosis of Healthcare-Associated Pneumonia (HCAP) is clinically out of date and does not effectively code.  The diagnosis of HCAP maps to the DRG for simple pneumonia.  Simple pneumonia is a diagnosis that can often be treated in the outpatient setting.  HCAP clearly does not fit into this DRG grouping, so physicians should update their clinical practice and their documentation.

Here’s why physicians should not document Healthcare-Associated Pneumonia:

  • The diagnosis of HCAP is clinically out of date.
  • HCAP does not code effectively.
  • The use of HCAP as a diagnosis is discouraged by the Infectious Diseases Society of America.
  • HCAP is the wrong diagnosis!

Pneumonia, and medical necessity for inpatient admission

Oral antibiotics are extremely effective in treating simple pneumonia. If a patient truly demonstrates medical necessity for inpatient admission to the hospital, the patient likely has either complex pneumonia or sepsis. (Severe) sepsis is now defined as organ dysfunction due to the infectious process, however, physicians often fail to link the pneumonia with the organ dysfunction. Physicians should update their documentation practices.

As an example: a patient is admitted to the hospital with the diagnoses of pneumonia and acute kidney injury (AKI). Effective documentation would link the conditions as “pneumonia causing AKI.” When pneumonia causes the AKI, then the physician should properly diagnose the patient with sepsis or severe sepsis, explicitly linking the organ dysfunction to the infection.

Allow antibiotics to drive the documentation

It is exceedingly common for physicians to admit patients to the hospital and treat them with very aggressive antibiotics without adequately documenting a diagnosis to support the reason why “big-gun” antibiotics are necessary. Physicians should allow their choice of antibiotics to drive their documentation.

For example, the following language is clinically appropriate and codes effectively.

  • Zosyn, to treat suspected gram negative (pseudomonas) pneumonia
  • Vancomycin, to treat suspected MRSA pneumonia
  • Zosyn, Clindamycin or Flagyl, to treat suspected aspiration pneumonia

If hospitalists are scrutinized by length of stay metrics, they should understand that expected length of stay (LOS) is calculated using the documented diagnoses. Suspected gram-negative pneumonia creates a longer expected LOS in the hospital than does simple pneumonia.

Our physician-to-physician education creates savvy documenters who understand how to use coding-based language to demonstrate medical necessity and accurately calculate the DRG. With our support, physicians can learn to document effectively to capture the patient’s severity of illness to support the DRG and quality metrics.

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