Pulmonology Coding Alert

Tip: Other conditions 'mimic' ventilator-associated pneumonia and can lead to misdiagnosis. Ventilator-associated pneumonia (VAP) is a difficult diagnosis to make, but once the pulmonologist diagnoses it in a patient, your E/M options may increase. Maintain diagnostic accuracy and pinpoint E/M levels with these from-the-field VAP coding tips. Be Precise When Reporting VAP When you come across a case of suspected VAP (997.31), consider how long the patient has been on a ventilator before showing signs of pneumonia. In general, VAP refers to pneumonia that occurs more than 48 hours after endotracheal intubation, according to the Cleveland Clinic (www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/health-care-associated-pneumonia). While diagnosis may seem straightforward, "the diagnosis of VAP is challenging," remarks Steven M. Gordon, MD, chairman of the department of infectious disease in the Medicine Institute at the Cleveland Clinic in Ohio. Often, pulmonologists do not perform bronchoscopies to obtain specimens or order chest computed tomographies (CTs) when making a [...]