Q&A: Appealing gram-negative pneumonia denials
Q: I've noticed an increase in denials for diagnoses of gram-negative pneumonia. How can we ensure that our providers are accurately documenting the appropriate clinical indicators?
A: There are a few things that make gram-negative pneumonia a tricky diagnosis when it comes to denials. Lack of appropriate treatment (not just on one or two broad spectrum antibiotics like Levaquin or Azithromycin) is one issue I frequently see. Lack of clinical indicators, such as not including a chest x-ray, mention of sputum, or recent hospitalization on the patient chart is another reason.
When I review a case to evaluate the validity of a gram-negative pneumonia diagnosis, I look for the following indicators:
- Elevated temperature
- Mucopurulent sputum
- Intravenous antibiotics or chemotherapy in the last month
- Nursing home residence
- Recent acute care hospitalization within the last 90 days
- Dependence on hemodialysis and/or immunocompromised
- Radiology findings of a “patchy” infiltrate
- Sputum culture
- Elevated white blood cell count
The treatment is also an important consideration. Is more than one antibiotic being used, and do they reflect treatment of gram-negative organisms? If several of these indicators are not present, I send a clinical validation query. Also, if several indicators are present and the diagnosis of a simple pneumonia has been documented, I will query for the gram-negative pneumonia as it better reflects the level of care provided.
In reviewing a denial, I look to see if the auditor has mentioned a lack of documentation of the above criteria. If the clinical criteria are present and have been omitted by the auditor in their denial letter, your appeal will likely be successful.
For more information, see "CDI tips for top denied diagnoses" by Brian Simpson, MS, RRT, CCDS, CDIP, CCS, CRC in the January issue of HIM Briefings.