Pulmonology Coding Alert

Ventilator-associated pneumonia (VAP) is in the undesirable category of hospital-acquired conditions -- but if CMS has its way, the need for making the diagnosis would occur much less frequently.

CMS has tried to place VAP (997.31) into the "nonreimbursable event" category of hospital-acquired diseases and conditions that carriers will not pay for. This category includes events such as operating on the wrong limb, leaving equipment in the patient, etc., says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta. "So far this attempt has been blocked from happening by the pulmonary and critical care community ... but most feel that CMS will attempt to place VAP back on the list in the future."

Given VAP's potentially negative ramifications, hospitals are wise to use VAP-preventive measures and to monitor any suspected VAP cases to be certain before making the diagnosis, comments Jill M. Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich.

Much of the grey area derives from VAP being a "diagnosis of exclusion." For instance, the cause of pneumonia may be difficult to determine if the patient decompensated quickly and the physician did not order a chest X-ray. Even if the provider orders a chest X-ray or a culture, getting an accurate diagnosis is still not guaranteed.

Bottom line: Don't be too quick to report 997.31 on patients who are ventilated and showing signs of pneumonia. First, consider the patient's history and possible alternate diagnoses. Attempt to confirm VAP with a trachea culture combined with a new or enlarging infiltrate chest X-ray, or a bronchoscopy plus bronchoalveolar lavage with a new or enlarging infiltrate chest X-ray, relates Young. Search for another diagnosis if cultures are negative. For more on VAP diagnoses, refer to the cover page article in this issue.