Pneumonia

Diagnosis: Pneumonia

Applicable for MSDRGs: 177, 178, 179, 193, 194, 195

MD documentation should address:

1. Presenting symptoms: respiratory effort and rate; lung sounds; fever or hypothermia; SNF or home health pt; presence of PEG tube or dysphagia
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. EKG: new findings and subsequent changes
4. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
5. Evidence of SIRS:Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
6. Sputum/C&S Findings: specify causative organism
7. Organisms, bacteria treated with medications or antibiotics (i.e. pseudomonas, strep, MRSA).
8. Type of pneumonia (bacterial, viral, aspiration)
9. If there is no sputum culture or x-ray which supports the pneumonia diagnosis, the physician may still document pneumonia as the final diagnosis based on his/her clinical judgment and treatment plan. Can document “possible”; “probable”; “suspected”
10. Pneumonia may still be sequenced as principal based on the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach
11. Treatment with medications or antibiotics, even if organism is presumed
12. Treatment with procedures or therapies

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