Question

Which of the following may legitimately change the coding of the pneumonia in accordance with the UHDDS and relevant clinical documentation?

1) Sputum culture reflects growth of normal flora.
2) Patient has a positive gram stain.
3) Patient is found to have dysphagia with aspiration.
4) Patient has nonproductive sputum.

Answer 1

According to the UHDDS and relevant clinical documentation, certain criteria may legitimately change the coding of pneumonia. A positive gram stain and dysphagia with aspiration are clinical indicators that support the diagnosis and can change the coding.

Step-by-step explanation:

According to the UHDDS (Uniform Hospital Discharge Data Set) and relevant clinical documentation, there are certain criteria that may legitimately change the coding of pneumonia. In the case of coding pneumonia, it is important to consider the presence of positive clinical indicators that support the diagnosis. Let's analyze the given options:

1. Sputum culture reflects growth of normal flora: This does not provide evidence of pneumonia, as the growth of normal flora in sputum culture is not indicative of an infection.
2. Patient has a positive gram stain: A positive gram stain is a direct microscopic examination method used to identify bacterial involvement. This supports the diagnosis of pneumonia and could legitimately change the coding.
3. Patient is found to have dysphagia with aspiration: Dysphagia with aspiration is a clinical indicator that suggests pneumonia. Therefore, it can legitimately change the coding.
4. Patient has nonproductive sputum: Nonproductive sputum does not provide clear evidence of infection, making it less likely to significantly change the coding of pneumonia.

Based on this analysis, options 2 and 3, which include a positive gram stain and dysphagia with aspiration, respectively, may legitimately change the coding of pneumonia.