Respiratory failure as PDx
Good afternoon - I need some tricks of the trade...
In the past couple of weeks I was involved with 3 cases, all intubated in ER, all on vents for up to one week, all with documentation either up front or concurrent query for "Acute Respiratory Failure, present on admission."
One went to DRG 310 arrhythmia w/MCC.
Another DRG 637 - diabetes w/MCC
And DRG 64 - stroke w/MCC
So of course we did not capture the vent and the approximate reimbursements do not accurately reflect the use of healthcare resources. Even though I thought I had pretty compelling evidence why the resp failure should be PDx, could not convince the coders to change their mind.
Has anyone come up with a plan on nailing some stronger verbiage from physicians to get the coders to use the resp failure as the PDx?
Sometimes I get a little discouraged...
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
In the past couple of weeks I was involved with 3 cases, all intubated in ER, all on vents for up to one week, all with documentation either up front or concurrent query for "Acute Respiratory Failure, present on admission."
One went to DRG 310 arrhythmia w/MCC.
Another DRG 637 - diabetes w/MCC
And DRG 64 - stroke w/MCC
So of course we did not capture the vent and the approximate reimbursements do not accurately reflect the use of healthcare resources. Even though I thought I had pretty compelling evidence why the resp failure should be PDx, could not convince the coders to change their mind.
Has anyone come up with a plan on nailing some stronger verbiage from physicians to get the coders to use the resp failure as the PDx?
Sometimes I get a little discouraged...
Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com
Comments
as prdx? It's hard to say why they would not without more details.
For a dx to be principal, it has to be present on admission and the
condition established after study to have occasioned the admission. I
am wondering if they are getting caught up with the 'underlying
cause'conundrum?
The Coding Clinics below in bold discuss acute respiratory failure
occurring with other acute conditions that are the 'underlying cause' of
the respiratory failure. They all state the resp failure can be the
prdx.
Only suggestions off the top of my head would be:
* Have physician actually state admission was for treatment of
acute respiratory failure
* Perhaps use the following Coding Clinics when discussing with
the coders
o Exacerbation of Myasthenia gravis with respiratory failure Coding
Clinic, Fourth Quarter 2004
* Acute respiratory failure can be principal dx with acute
non-respiratory dx.
o Aspiration pneumonia and acute respiratory failure - clarification
Coding Clinic, First Quarter 2008
o Respiratory Failure series in First Quarter 2005
* Respiratory failure w/myasthenia gravis exacerbation
* Respiratory failure w/emphysema
* Respiratory failure and congestive heart failure
* Respiratory failure due to status asthmaticus
* Respiratory failure due to postpartum pulmonary embolism
* Respiratory failure due to crack overdose
* Respiratory failure due to AIDS related Pneumocystis carinii
* Respiratory failure and sepsis
Hope this helps or at least leads to a discussion of the issue -
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
as prdx? It's hard to say why they would not without more details.
For a dx to be principal, it has to be present on admission and the
condition established after study to have occasioned the admission. I
am wondering if they are getting caught up with the 'underlying
cause'conundrum?
The Coding Clinics below in bold discuss acute respiratory failure
occurring with other acute conditions that are the 'underlying cause' of
the respiratory failure. They all state the resp failure can be the
prdx.
Only suggestions off the top of my head would be:
* Have physician actually state admission was for treatment of
acute respiratory failure
* Perhaps use the following Coding Clinics when discussing with
the coders
o Exacerbation of Myasthenia gravis with respiratory failure Coding
Clinic, Fourth Quarter 2004
* Acute respiratory failure can be principal dx with acute
non-respiratory dx.
o Aspiration pneumonia and acute respiratory failure - clarification
Coding Clinic, First Quarter 2008
o Respiratory Failure series in First Quarter 2005
* Respiratory failure w/myasthenia gravis exacerbation
* Respiratory failure w/emphysema
* Respiratory failure and congestive heart failure
* Respiratory failure due to status asthmaticus
* Respiratory failure due to postpartum pulmonary embolism
* Respiratory failure due to crack overdose
* Respiratory failure due to AIDS related Pneumocystis carinii
* Respiratory failure and sepsis
Hope this helps or at least leads to a discussion of the issue -
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
Debby Dallen,RN CCDS
Clinical Documentation Coordinator
Albert Einstein Medical Center
Phila PA 19141
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
is leaving $$$ on the table, something CDI folk hate to do. Our coders
definitely pick this up.
Jamie Dugan RN
Baptist Health System
Jacksonville, Florida
Office 904-202-4345
Every chart stands on its' own documentation, but as a coder I would be hard pressed to leave that much money on the table if I could defend Acute Respiratory Failure as my principal. Do you have a coding manager or a coding consultant you could refer cases to for further review? If you could sum up cases might could send to 3M nosology for review.
I attached a few coding clinics that might help support Respiratory Failure argument.
Good Luck!
Coding Guidelines
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis
When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.
C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
Respiratory failure
Coding Clinic, First Quarter 2005 Page: 3 to 4 Effective with discharges: April 20, 2005
Related Information
Respiratory Failure
Note from 3M:
As of October 1, 2011, codes have been created to distinguish postoperative acute respiratory failure from less severe respiratory conditions. See Coding Clinic, Fourth Quarter 2011, pages 123-125 for more information.
The Central Office has continued to receive numerous requests regarding the sequencing of respiratory failure. The following instruction has been developed by the Cooperating Parties to provide clarification. Some of the principles outlined below are consistent with previously published advice, and some contain revised information. Please review carefully these principles along with the accompanying examples.
Code 518.81, Acute respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence. Respiratory failure may be listed as a secondary diagnosis if it occurs after admission.
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident), the principal diagnosis will not be the same in every situation. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are responsible for occasioning the admission to the hospital, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C,) may be applied in these situations.
The advice above supercedes guideline #1 and guideline #2, previously published in Coding Clinic, Second Quarter 1991, page 3. This information is consistent with advice previously published in Coding Clinic, November-December 1987; Second Quarter 1990, page 11-12; Third Quarter 1991, page 14; First Quarter 1993, page 25;Second Quarter 2000, page 21; and First Quarter 2003, page 15.
Respiratory failure is a life-threatening condition that is always due to an underlying condition. It is usually the final pathway of a disease process, or a combination of different processes. It can arise from an abnormality in any of the components of the respiratory system, central nervous system, peripheral nervous system, respiratory muscles and chest wall muscles. Patients with acute respiratory failure require repeated assessments and close observation. The primary thrust of treatment is usually towards correction of the hypoxemia and stabilization of the ventilatory and hemodynamic status.
Respiratory failure w/myasthenia gravis exacerbation
Respiratory failure w/emphysema
Respiratory failure and congestive heart failure
Respiratory failure due to status asthmaticus
Respiratory failure due to postpartum pulmonary embolism
Respiratory failure due to crack overdose
Respiratory failure due to AIDS related Pneumocystis carinii
Respiratory failure and sepsis
(c) Copyright 1984-2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
Dorie Douthit, RHIT,CCS
ddouthit@stmarysathens.org
respiratory failure as the principal diagnosis. Again, I would refer
them to the Coding Clinics cited earlier. The myasthenia gravis,
aspiration pneumonia and status asthmaticus are great examples of the
same type of cases since they specifically state the underlying cause
was also 'acute' at the time.
If your facility uses 3M's encoder, you could refer the cases to them
and see what they say. You don't have to be a coder to ask 3M's
nosology department a question. Just click on 'contact us'. If you
have not used it before, you need to register. After that, you can ask
a question by calling or doing it online.
If you can't bring them to see your rationale, taking a step up the
ladder is probably necessary.
Good Luck!
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
-Jane
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, August 22, 2012 8:46 AM
To: Hoyt, Jane RN
Subject: RE: [cdi_talk] Respiratory failure as PDx
They said it really wasn't the reason that occasioned the admission to the hospital. For example, the CVA pt wouldn't have had resp failure if it wasn't for the stroke. The diabetic would not have resp failure if it wasn't for the hypoglycemia, etc.
Another thing to consider is medical necessity. Intubation and ventilator management are medically necessary in acute instances. What was the medically necessary treatment for the CVA and the hypoglycemia? If those treatments did not meet medical necessity for an inpatient stay - I would hesitate to use the diagnoses associated with them as my PDX.
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
I'm retrospectively reviewing a death chart with this scenario now. We did virtually nothing for the arrest/MI. She was resuscitated at the outlying facility prior to transfer and was only at our facility for
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, August 23, 2012 11:56 AM
To: Mancini Laura
Subject: RE: [cdi_talk] Respiratory failure as PDx
What about when you have a cardiac arrest (underlying cause later determined to be MI) with resp failure (intubated prior to transfer to our facility).
I'm retrospectively reviewing a death chart with this scenario now. We did virtually nothing for the arrest/MI. She was resuscitated at the outlying facility prior to transfer and was only at our facility for
treatment.
When a patient is admitted with respiratory failure and another acute
condition, (e.g., myocardial infarction, cerebrovascular accident), the
principal diagnosis will not be the same in every situation. Selection
of the principal diagnosis will be dependent on the circumstances of
admission. If both the respiratory failure and the other acute condition
are responsible for occasioning the admission to the hospital, the
guideline regarding two or more diagnoses that equally meet the
definition for principal diagnosis (Section II, C,) may be applied in
these situations.
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, August 23, 2012 8:56 AM
To: Salinas, Sharon
Subject: RE: [cdi_talk] Respiratory failure as PDx
What about when you have a cardiac arrest (underlying cause later
determined to be MI) with resp failure (intubated prior to transfer to
our facility).
I'm retrospectively reviewing a death chart with this scenario now. We
did virtually nothing for the arrest/MI. She was resuscitated at the
outlying facility prior to transfer and was only at our facility for
Is this a coding rule with poisoning? Thank you in advance for any insight.
-Jane
The code for bronchospasm (519.1) is assigned only when the underlying cause has not been identified.
Francisca Wojciechowski BS, RHIA, RHIT, CCDS
AHIMA-Approved ICD-10-CM/PCS Trainer
based on injury and poisoning coding guidelines Chapter 17.e.2.b & e.
It has nothing to do with the bronchospasm. When a poisoning is
involved, the poisoning code is always principal followed by the
condition the poisoning caused. Below are some examples from Coding
Clinic.
Respiratory failure due to crack overdose
Coding Clinic, First Quarter 2005 Page: 6 to 7 Effective with
discharges: April 20, 2005
A patient who is diagnosed as overdosing on crack is admitted to the
hospital with respiratory failure.
Principal diagnosis:
970.8 Poisoning by other specified central
nervous system stimulant
Secondary diagnosis:
518.81 Acute respiratory failure
305.60 Nondependent abuse of drugs, cocaine
abuse, unspecified
888888888888888888888888888888888888888888888888888888
Crack overdose with respiratory failure
Coding Clinic, First Quarter 1993 Page: 25 Effective with
discharges: January 1, 1993
Related Information
Question:
How do you code the patient who is diagnosed as overdosing on crack and
found to be in respiratory failure, then placed on ventilation? Wouldn't
the poisoning code be the principal diagnosis?
Answer:
Yes, you are correct. The principal diagnosis in this case would be the
code for the overdose, 968.5, Poisoning by other central nervous system
depressants and anesthetics, Surface [topical] and infiltration
anesthetics. In addition, assign code 305.60, Nondependent abuse of
drugs, Cocaine abuse, unspecified, and code 518.81, Other diseases of
lung, Respiratory failure. It would be incorrect coding to select
respiratory failure as the principal diagnosis just because the patient
is placed on ventilation. Specific coding examples of poisoning and drug
overdose can be found under PDX #14, Poisoning, in Coding Clinic for
ICD-9-CM, Second Quarter 1990, page 11.
Note from 3M:
As of October 1, 2002 the coding of cocaine/crack overdose has been
changed to 970.8.
Note from 3M:
As of October 1, 2010, code 970.8 has been expanded and a unique code
(970.81) has been created to identify cocaine poisoning.
(c) Copyright 1984-2012, American Hospital Association ("AHA"), Chicago,
Illinois. Reproduced with permission. No portion of this publication may
be copied without the express, written consent of AHA.
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
8. Chapter 8: Diseases of Respiratory System (460-519)
c. Acute Respiratory Failure
1) Acute respiratory failure as principal diagnosis
Code 518.81, Acute respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.
2) Acute respiratory failure as secondary diagnosis
Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.
3) Sequencing of acute respiratory failure and another acute condition
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.
If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.
The rule you cited was replaced with the above.
Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336
Thanks for all of your references Sharon!!
Jane
Sent from my U.S. Cellular© Smartphone
I agree with Sharon both on the poisoning as PDx, and on the current guidelines for sequencing respiratory failure. That rule about taking the non-respiratory diagnosis was superseded several years ago.
Renee
Linda Renee Brown, RN, CCRN, CCDS, CDIP
Dawn M. Vitalone, RN, CCDS
Clinical Documentation Improvement Specialist
Community Hospital
Munster, IN