Documentation Tip of the Week: Aspiration Pneumonia

Posted on Wed, May 27, 2015
Documentation Tip of the Week: Aspiration Pneumonia

Aspiration Pneumonia

Aspiration pneumonia codes to a complex pneumonia and shows that your patient is severely ill.

Consider this diagnosis when the patient has the following risk factors:

  • Dysphagia
  • Failed swallow study
  • RLL pneumonia
  • Advanced age
  • Nursing home resident
  • Alcoholism

Please document this diagnosis when you choose selected antibiotics:
  • Flagyl
  • Clindamycin
  • Zosyn
Remember- Hospital documentation can include “possible, probable, likely or suspected“ diagnoses

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at

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