Q&A: Community-acquired pneumonia

Q: How do we determine if a patient’s pneumonia is community acquired or not? What documentation should we look for to support this?

A: To be honest, any type of pneumonia can be acquired in the community. However, physicians often use the term “community acquired” to signify a simple pneumonia. Simple pneumonia is usually easily treatable, although the term is somewhat self-limiting. The diagnosis causes unique problems for CDI specialists.

In general, simple pneumonia cases would not and should not be admitted to the hospital for inpatient status. They could be admitted, however, if they have a number of other medical problems that further complicate the care of their pneumonia, or are becoming acute themselves—for example, a congestive heart failure (CHF) patient getting fluid overloaded, a diabetes patient with an out-of-control blood sugar level, or a very elderly patient who also has a urinary infection and has now become confused.

We certainly would not want to make a blanket statement that any patient admitted to the hospital probably has a gram-negative or complex pneumonia. But, oftentimes, the pneumonia by itself does not support the admission.

“Atypical” is a term used by physicians to describe a unique presentation of pneumonia that has its own set of chest x-ray findings, history, and treatment requirements. Generally, atypical pneumonia is usually caused by one of the organisms classified as a complex pneumonia for DRG assignment purposes. Unfortunately, the term “atypical” codes to one of the simple pneumonia types.

Interestingly enough, “hospital acquired” and “healthcare acquired” are almost always written when the physician is attempting to describe a more complex pneumonia, resistant to treatment, in a patient who has a higher acuity illness. Unfortunately, these terms code to simple pneumonia classifications, too. Physicians are almost always surprised (and often disagree) with these phrases being classified as “simple.”

For this reason, what I teach CDI specialists to ask for the specific organism, and to either document that organism as either confirmed or suspected at discharge. Getting the exact organism is not always possible. Nevertheless, physicians need to document their assessment based on the same clinical evidence that caused them to treat that patient in one manner versus another.

For CDI specialists, the moral here is that when physicians document “atypical,” “hospital-acquired,” and “healthcare-acquired” you may need to craft a query, so providers don’t get an inappropriate downgrade.

Furthermore, CDI specialists may need to query the physician regarding patients sick enough to be admitted to the hospital for community-acquired pneumonia, particularly if the physician did not include any additional documentation regarding comorbidities. It may be that the patient actually has sepsis, or reveal a more specific causative organism which changes the classification to a more complex pneumonia.

Worst case scenario, a reassessment of the utilization procedures may need to occur if a large population of simple pneumonias is actually being admitted with no complications, no co-morbidities, no risk factors, and they genuinely do have simple gram positive type pneumonias.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question on the CDI Blog. Contact him at AFrady@hcpro.com.