Inpatient Facility Coding & Compliance Alert

Question: A patient was admitted with a chief complaint of shortness of breath. He also had a cough with green sputum production, and has a history of COPD. The physician determined that the patient had pneumonia, and prescribed antibiotics. The physician also documented that the patient had COPD exacerbation for which CPAP was administered. What should we consider as the principal diagnosis?

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Answer: The patient’s pneumonia and COPD were both treated during this admission, and are co-equals for being a principal diagnosis. You can sequence either one first, but would likely select the one that received the most intense services.

Check: Since the patient had CPAP treatment, verify whether it was invasive (with an endotracheal tube/ETT) or non-invasive (with no mention of ETT in the chart). There is a significant difference in DRG weight depending on whether invasive or non-invasive mechanical ventilation was used.

The COPD with exacerbation has a higher DRG than pneumonia. Because you have documentation that the COPD was treated with respiratory therapy (CPAP) that will most likely be the correct principal diagnosis.

For DRG coding, potential assignments could include 191 (Chronic obstructive pulmonary disease W CC) for the COPD and 194 (Simple pneumonia pleurisy W CC) for the pneumonia. Collect all other codes that apply to the admission and group them according to the two conditions for comparison before making your final DRG assignment.