Pulmonology Coding Alert

Question: The physician states that the primary discharge diagnosis for his hospitalized patient is pneumonia (486). A sputum sample grew staph aureus.

The pneumonia was treated with IV antibiotics, and the patient was discharged home on oral antibiotics, appropriate for treatment of a staph aureus infection. Do you need the physician to state staph aureus pneumonia in the record before you could code this as (482.41)?

New York Subscriber


Answer: Yes, the physician needs to authenticate the reason he ordered the treatment of a staph aureus infection (482.41). This information can be included in his discharge summary and does not need to be reported separately. A statement such as based on the laboratory findings dated month, day and year, indicating a staph aureus infection, the patient is being treat with oral antibiotics. The American Medical Associations documentation guidelines include specific directions that services, procedures and care provided and reported for billing purposes must be documented in the medical record.

Clearly, as more records are being audited to determine accuracy of documentation, it is essential to remember, If it isnt documented, it didnt happen. The payer could deny payment for the staph aureus antibiotic if there is no documentation for why the provider prescribed the medication based on his medical record.