ICD-10 DRG Target Areas – Aspiration Pneumonia and COPD
Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s case study below:
CASE SCENARIO #1
87-year-old female with a history of ESRD, COPD and pneumonia (PNA) presents to the Emergency Room with complaints of chest pain and SOB. She had presented to Emergency Room a week earlier with same complaints and started on P.O antibiotics and discharged home. She started to feel progressively worse and came back to the Emergency Room and was admitted. She was started on IV Vancomycin, IV Zosyn, duoneb and O2 2L NC. The final diagnosis was likely COPD exacerbation due to hospital acquired pneumonia.
*Full listing of secondary code assignments not shown
CASE SCENARIO #2
83-year-old female with a history of ESRD, COPD and pneumonia (PNA) presents to the Emergency Room with complaints of chest pain, SOB and coughing with “greenish” phlegm. She was wheezing and CXR shows infiltrate in the posterior segment of the LLL. She was started on IV Clindamycin, duoneb and O2 2L NC. Final diagnosis was COPD exacerbation due to aspiration pneumonia.
AUDIT CONSIDERATIONS & STRATEGIES
- If a patient is admitted with pneumonia due to COPD exacerbation, assign 0 – COPD with acute lower respiratory infection as the principal diagnosis
- Even if a patient is admitted with pneumonia and the COPD is not in exacerbation (i.e. history of COPD), the principal diagnosis is the COPD
- The only exception to this rule is if a patient is admitted with aspiration pneumonia and COPD, in this scenario, assign aspiration pneumonia as the principal diagnosis
- In many ways, these sequencing rules contradict conventional coding and clinical logic, however, these are the rules as they stand today and they must be followed
- The only reason that aspiration pneumonia is an exception to the rule is because it is categorized in section, “Lung diseases due to external agents” rather than the “Respiratory Infection” section (which are all included in the sequencing rule)
- For the time being coders must continue to sequence COPD as the principal diagnosis for all patients presenting with pneumonia and COPD (whether acute or compensated)
- Aspiration Pneumonia and Chronic Obstructive Pulmonary Disease Coding Clinic – 1st Quarter 2017: Page 24
- Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Pneumonia Coding Clinic – 3rd Quarter 2016: Page 15-16