Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
A: I'm sorry to tell you no, unfortunately, we are specifically not permitted to make that leap even when it is obvious. According to the ICD-10 CM official guidelines for reporting ventilator associated pneumonia, the providers must specifically document the relationship between the pneumonia and the ventilator. This is not a grey area.
If you do have patients who are on ventilators, then take a look at the documentation you have now. Are your physicians documenting the connection? If they are not already documenting the specific connection, then you're going to need to discuss this with them and you're going to need to get them to do it.
You can address the connection in two ways. You or your clinical documentation improvement specialists can query the physician. Or you can ask your IT department to insert an alert in the EHR so that when the physician documents the patient's been on a ventilator and has pneumonia, an alert box might appear to ask the physician, is this cause and effect?
I definitely think it’s an important thing to address. Start now even though we know ICD-10 has been delayed.
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Fla., answered this question. Shelley is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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