COPD exacerbation

leimapaloleimapalo
in CDI Talk Archive
If a pt w/ severe COPD, uses home 02 (no documentation of chronic resp failure) and comes in for COPD exacerbation, is it appropriate to query for "acute on chronic respiratory failure" or just focus on the "chronic resp failure"?
I am wondering bec pts who come in in exacerbation are almost always in resp failure w/ RR > 24, etc. My train of thought is that the acute resp failure part is built-in the exacerbation dx.

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    My query for resp failure give clinical indicators and then give the options for Acute, chronic, acute on chronic resp failure as well as resp distress/hypoxia, other, unknown, etc.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • paxnerospaxneros
    edited May 2016
    What's your ABG's? If they are Severe COPD their pCO2 and HCO3 are
    chronically elevated qualifying for Chronic . If they are acidotic you could
    query for Acute on Chronic.

    NBrunson, RHIA, CDIP, CCDS
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    What is the difference if you choose to query for “acute resp failure” versus “chronic resp failure”? Are you including different clinical indicators?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • sharon.colesharon.cole
    edited May 2016
    We always check the ABGs and for other s/s: accessory muscle use, cyanosis, retractions, etc before querying.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org
  • paxnerospaxneros
    Yes. We go by CDI Pocket Guide by Pinson & Tang- pg. 38-39 under Key References:

    Patient should have both difficulty breathing and a blood gas impairment.

    1.) Diff. Breathing could be documented as SOB, dypsnea, hypoxemia, resp distress, use of accessory muscles, Resp Rate of >30


    Type I : pO2 50 and usually pH
  • mdomineseymdominesey
    edited May 2016
    Here is the query that I developed. I included the diagnoses of type I and type II respiratory failure which will be pertinent for ICD-10. Physicians have been receptive to this query and format.

    Mark

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • dvitalone1dvitalone1
    edited May 2016
    I'm a little confused. When a pt has h/o COPD and is on continuous home 02 a query is warranted for chronic respiratory failure....how can you offer choices of resp failure if it is not mentioned in the record?
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I like it Mark. You just reminded me that we need to add the Types to our current query for ICD-10 purposes.

    Mine is similar in that I offer all options on the query (acute, chronic, acute on chronic, etc). This is why I was confused by the original question about WHICH one to query for, since in my mind a query would have both options, regardless. That doesn't mean I don’t have an idea as to which I think it is when I query. I do have two separate queries for resp failure, Acute and Chronic only because I have different indicators for both because if a chronic failure is compensated I don’t use my acute resp failure query. However, if I am not sure if there is an acute failure or not, I use the Acute resp failure one and then also include the underlying diagnosis causing the chronic failure, home 02, etc as well as any acute issues.

    I attached mine as well.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I query for chronic resp failure when a patient has an underlying resp issue that requires HF 02, CPAP, etc. I'm not saying that I necessarily query for every patient on home 02 though (I'm not sure if that’s appropriate or not, I'd love to hear others opinions on that). But especially if it’s a chronic, progressive issues like emphysema, end-stage COPD, ALS, etc, I generally query. My query does not state the diagnosis of resp failure but it does list the types of failure as response options, as well as other options. I attached it in my prior response.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • mdomineseymdominesey
    edited May 2016
    There are two types of queries often warranted. The initial query would be to ask them for a diagnosis to go along with the clinical indicators (this is a "tx without diagnostic indication" or "clinical significance"). If a non-specific response is returned to that query, then a query for specificity is warranted.

    The query I sent a few minutes ago is a query for specificity, meaning they already documented "respiratory failure" in the record. They are asked to clarify/specify which type and acuity/chronicity of respiratory failure is present. If they already documented chronic respiratory failure, then a different tack is in order.

    If someone comes in with an acute exacerbation of COPD and has the clinical indicators of acute respiratory failure (RR up, ABGs out of whack, possible somnolence/delirium due to lack of O2, dyspnea) then an acute respiratory failure is an appropriate physician response to a documentation clarification query

    Kindest Regards,

    Mark


    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • paxnerospaxneros
    edited May 2016
    We have 3 queries - Chronic, Acute and Acute on Chronic. Each query
    includes all terminology as choices. I use each according to the medical
    condition presented by the patient.

    However, Chronic only includes Chronic Clinical Indicators, Acute includes
    Acute, and likewise Ac/Chr w/ both sets of indicators.

    The Chronic Query I use for patients who have Hx of COPD w/Chronically low
    pCO2/HCO3 and on home O2. These patients walk around w/O2 Sats that meet
    "Acute" status but they are not considered Acute.

    If they are not admitted in an exacerbated state then I at least want the
    physician to document their Chronic Resp Failure which will be monitored in
    an Acute Care setting by registered and licensed FTE's. Chronic will be my
    CC in many instances.

    Just of note- "Respiratory Failure" will automatically code to "Acute".

    NBrunson, RHIA,CDIP,CCDS
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Mark: I like the fact you referenced evidence-based clinical indicators
    with citation of the sources for the same on the respiratory failure
    query - I think it is important to do so in order to try to 'define' a
    process in an effort to ensure consistency in documentation - I believe
    this helps to 'defend' subsequent coding, when required.

    Our query form is very similar to yours and was developed by our
    consultant, FIT, (James Kennedy, MD, CCS). I can't attach this
    given it is proprietary - but it has some of the elements you have
    employed - notably, incorporation and citation of commonly accepted
    criteria for this condition.



    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • MelindascharfMelindascharf
    edited May 2016
    Great query Mark. We have a lot of trouble with the docs documenting chronic respiratory failure and we have been looking for criteria to add to our query. We get so much "end stage copd"!!
    Thank you!

    Melinda Scharf RN BSN CCDS
    St Joseph Hospital
    714-771-8000 ext:18119
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    If COPD is documented I actually just ask for the status. I state where is it documented, sx, and the treatment provided, etc and ask for the acuity.
    -exacerbation
    -Compensated
    -other
    -Unable to determine


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • tkreilingtkreiling
    edited May 2016
    Thanks, that is exactly what I was thinking but just wasn't quite sure!! I appreciate it.
  • robert.hodges2robert.hodges2
    edited May 2016
    What Katy said. If the COPD is already documented I only query for status.

    Robert
     
    VA Core Values:  Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
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    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
  • ddouthitddouthit
    edited May 2016
    Based on your knowledge of the patient and the below clinical indicators are you able to determine the acuity of the patient’s COPD?

    • COPD exacerbation

    • COPD stable

    • Other more appropriate diagnosis _________________________

    Unable to determine

    Dorie Douthit, RHIT,CCS
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I would just write a query stating that COPD is documented in the record. Include any clinical indicators of an exacerbation that may be in the record as well as the treatments.
    I would then ask if they could specify whether the COPD being treated was:
    Compensated
    Exacerbation
    Other___________
    Unable to determine

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • mdomineseymdominesey
    edited May 2016
    I like Katy's approach. I assume you are pursuing this solely based on the quality of the documentation and the impact of severity and risk? If your principle DX is COPD, then your MCC in pneumonia. If your principle is pneumonia, then you definitely have a good reason to see if it has contributed to a decompensation of the COPD (which then makes COPD a CC, but, you could also get "chronic respiratory failure" as another CC and this is a common DX for those with COPD).

    Kindest Regards,

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital
    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695
    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    http://www.sibley.org
  • yuliyafishyuliyafish
    edited May 2016
    Our is similar to Katy's. Attached.

    Yuliya Fish, RN, CCDS
    CDI-S
  • ssalinasssalinas
    edited May 2016
    Questions/Comments:
    Chronic obstructive airway disease is documented in the _____________. In order to accurately reflect the severity of illness of your patient, please clarify the specific type and acuity level of your patient’s obstructive airway disease (if known).

    Type of Chronic Obstructive Airway Disease:

    • Asthma (Chronic/Obstructive
    • Bronchiectasis
    • Bronchitis (Chronic/Obstructive)
    • Emphysema
    • COPD Unspecified
    Other _______________

    Acuity Level of Obstructive Airway Disease:

    • With Acute Exacerbation
    o Acute Exacerbation was _______________________________
    • With Status Asthmaticus
    • With Acute Bronchitis
    • Compensated/Stable
    • Unspecified

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    213-250-4200 Extension 3336
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