Look for Telltale Signs of Pneumonia (even when it’s not documented) 

By Brian Murphy

‘Tis the time of year for celebration … but also seasonal illnesses, including pneumonias. Yuck.

So here are a few things to keep in mind if you’re a coding or CDI professional.

Pneumonias are diagnosed through 1) signs and symptoms—elevated temperature/fever or hypothermia, chills, fever, confusion, cough, sputum production, and 2) typically an acute pulmonary infiltrate seen on a chest X-ray or CT scan.

But a problem is that the scan might not pick up the pneumonia, particularly if the patient is dehydrated or has severe leukopenia. Or, the pulmonary infiltrate might be present but obscured by interstitial lung disease, which shows up as white and obscures the pneumonia imaging.

A repeat x-ray can pick up the pneumonia but these aren’t always performed if the patient is improving.

So long story short, pneumonia can be missed by a physician. And clarified by a CDI or coding professional, who can with a query get the physician to document suspected pneumonia, for example. Recall possible/suspected/likely diagnoses can be coded in the inpatient setting.

DRG 195 (Simple pneumonia and pleurisy without CC/MCC) has a relative weight of 0.6256 and a geometric mean length of stay of 2.4 days. If the CDI review results in the addition of a major complication/comorbidity, it groups to DRG 193 (Simple pneumonia and pleurisy with MCC) with a relative weight of 1.3266, with a geometric mean length of stay of 4.1 days.

That’s financial and quality impact. Patient gets to stay longer and be treated accordingly.

Community acquired pneumonia (CAP) presents its own set of obstacles. An authoritative paper published by the American Thoracic Society in 2019 (link below) ended the use of the term “healthcare acquired pneumonia/HCAP” and revised the guidelines to include staphylococcus, pseudomonas, and other aerobic gram-negative bacteria CAP based on the presence of certain risk factors.

As in the above instance, a CDI or coding professional could step in to query for additional specificity, moving a simple community acquired pneumonia to a gram-negative pneumonia when clinical indicators warrant. A good place to look for evidence of the pneumonia type is the antibiotic order.

Complex pneumonias with an MCC group to DRG 177 (Respiratory infections and inflammations with MCC), which has a relative weight of 1.6964 and a geometric mean length of stay of 5.0 days. COPD is a common comorbid condition in these patients, per the paper referenced below (“gram-negative bacilli are more common causes of CAP in patients with comorbidities, such as COPD.”

All of the above work on pneumonia clarification impacts HCC assignments, too.

Much of the above credit to Dr. William Haik, whom I hosted on this topic on an ACDIS podcast back in the day.


ACDIS Podcast:


American Journal of Respiratory and Critical Care Medicine,

“Diagnosis and Treatment of Adults with Community-acquired Pneumonia”: https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

CMS, 2024 IPPS final rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page

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