Pneumonia

Definition

Pneumonia is an inflammation of the parenchyma of the lungs.  Most cases of pneumonia are caused by microorganisms. Non-infectious causes include aspirations of food or gastric acid, foreign bodies, hydrocarbons, lipoid substances, hypersensitivity reactions and drug/chemical pneumonitis.

Document the Cause of Pneumonia

Bacterial

  • Aspiration

  • Viral

  • TB

  • Fungal

  • Chemical

 

If unsure of the specific cause, "probable"/"treating for" capture most likely diagnosis. If specific antibiotics are used, document why: 

  • Zosyn --> “treating for” gram negative -or-  aspiration pneumonia 

  • Cefepime --> “probable” gram negative pneumonia 

  • Vancomycin --> “likely” staph aureus pneumonia 

  • Meropenem --> “suspected” gram negative pneumonia

Document Factors Suggesting Need for Hospitalizaiton

Respiratory Failure

  • Hypoxia/hypercarbia

  • Sepsis / toxic appearance

  • Failed outpatient therapy

  • Immunocompromised state

  • Dehydration

  • Sickle cell anemia with acute chest syndrome

Tips For Documentation

Document location, i.e. right lower lobe infiltrate

  • Link associated conditions (i.e. empyema, pleural effusions, and loculation) 

  • If specific viral pathogen (i.e. influenza, RSV, COVID-19) known, include in hospital note

  • Restate radiology and laboratory findings in the hospital notes because coding may not use these reports

  • Note preadmission treatment that may have affected radiology or laboratory results.

Quick Tips!

Document the LOCATION

  • Restate radiology findings

  • Document the ORGANISM or CAUSE if you know it

    • Restate laboratory findings

    • Knowing an organism is not required

  • Document the reason for HOSPITALIZATION

    • i.e. hypoxia, failed oral therapy, non-adherence, dehydration, age<6 months