Q&A: When is it appropriate to query for aspiration pneumonia?

December 6, 2011

QUESTION: A physician admitted a patient with pneumonia, which was the first diagnosis. The second diagnosis was malnutrition secondary to feeding difficulties of the elderly. Two days later, the physician inserted a percutaneous gastrostomy tube. A day or two later, the physician documented only that the patient had aspirated. Our clinical documentation analyst then queried the physician for aspiration pneumonia. I'm an inpatient coder, and we had a different viewpoint on this, and I wanted to get someone else's insight on this topic.

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