Question

A patient has a principal diagnosis of pneumonia (486) (MS-DRG 195). Which of the following may legitimately change the coding of the pneumonia in accordance with the UHDDS and relevant clinical documentation?

-Sputum culture reflects growth of normal flora.
-Patient has a positive gram stain.
-Patient is found to have dysphagia with aspiration.
-Patient has nonproductive sputum.

Answer 1

The coding of the pneumonia diagnosis may be legitimately changed based on factors such as sputum culture, gram stain, and dysphagia with aspiration.

Step-by-step explanation:

The coding of the pneumonia diagnosis may be legitimately changed in accordance with the UHDDS and relevant clinical documentation based on the following:

• Sputum culture reflects growth of normal flora: This may change the coding as it indicates that the pneumonia is not caused by an infectious organism.
• Patient has a positive gram stain: A positive gram stain indicates the presence of a specific type of bacteria and may change the coding to reflect the type of pneumonia.
• Patient is found to have dysphagia with aspiration: If the patient's dysphagia and aspiration are determined to be the direct cause of the pneumonia, the coding may be changed to reflect this.

Nonproductive sputum, on the other hand, does not have a direct impact on changing the coding of the pneumonia diagnosis.