respiratory failure following trauma or surgery 518.51 and 518.52

donna.kent

We are finding a problem that seems two fold:
1. MDs write "respiratory failure" which happens to occur following a surgery but in fact the patient is merely within the 48 hour weaning window from anesthesia.

2. Coders coding post-op resp.failure because a doc writes pulm insuffiency somewhere after surgery, it could be 5 or 6 days. Or #1.

While those 500 codes are not in the 900 series for complications, I believe these are considered complications because they are being interpreted as due to surgery/anesthesia.

We are planning a meeting with coding and the pulmonologists to address this. However, as I read Coding Clinic Fourth Quarter 2011, p123-125 I am now concerned that the interpretation by coding is bypassing the words "Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation." Emphasis on for more than 48 hours after surgery...

Sorry this is so lengthy but it seems a bit of a conundrm.

Donna

evanspx@sutterhealth.org

Difficult, advanced and complicated topic, hence a lengthy response. The fundamental problem will 'always' be that a coder 'must' code what is stated in the record. However, I believe the coding industry must reevaluate this philosophy.


I attached our formal approach to the topic and have extracted one portion below -



Postoperative Respiratory Failure
Many physicians document “acute respiratory failure” in the postoperative period, even though it is usual and customary for the procedure. This may occur when patients are maintained on a ventilator following surgery even though it is a routine and expected aspect of the patients care inherent to the procedure performed. In other words, the respiratory failure is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis.

As the CDI team reviews charts, we will not ‘code’ postoperative respiratory failure if there is not clinical support for this decision – ‘best practice’ would be to state in our notes section that “518.5X noted”. We will not use the documentation of ARF when we compute our working MS-DRG on our Reconciliation Sheet. The final coding decision will be made by the coder.

It ‘may’ be appropriate to code if:

 Physician documents it as not routinely expected or as a complication of the procedure
 Physician documents as due to another cause or due to medications or anesthesia
 Mechanical Ventilation is required for more than 48 hours after surgery or reintubation with mechanical ventilation is performed

Effective October 1, 2011, codes 518.51, Acute respiratory failure following trauma and surgery; 518.52, Other pulmonary insufficiency, not elsewhere classified; and 518.53, Acute and chronic respiratory failure following trauma and surgery, have been created to distinguish postoperative acute respiratory failure from less severe respiratory conditions such as shock lung, drowned lung, pulmonary and lung insufficiency following shock, surgery or trauma, wet lung syndrome, adult respiratory distress syndrome (following shock, surgery, or trauma) and acute idiopathic lung congestion; conditions that only require supplemental oxygen or intensified observation.

Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation. Risk factors may be specific to the patient's general health, location of the incision in relation to the diaphragm, or the type of anesthesia used for surgery. Trauma to the chest can lead to inadequate gas exchange causing problems with levels of oxygen and carbon dioxide. Respiratory failure results when oxygen levels in the bloodstream become too low (hypoxemia), and/or carbon dioxide is too high (hypercapnia), causing damage to tissues and organs, or when there is poor movement of air in and out of the lungs. In all cases, respiratory failure is treated with oxygen and treatment of the underlying cause of the failure. Source: AHA Coding Clinicâ for ICD-9-CM, 4Q 2011, Volume 28, Number 4, Pages 123-125


Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002
Fax:  415.600.1325
Ofc:  415.600.3739
evanspx@sutterhealth.org

katysuegood@gmail.com

I am tagging onto an old thread here but I have a question about coding of post-op resp failure that I am hoping you can help me with. I recently looked at a chart one of the CDI’s sent me and noticed that the MD had documented resp failure after surgery. The patient came in with a perforated gastric ulcer and underwent an Ex-Lap where they patched the perforation. They say that there were no complications in the immediate post-op note. She was kept on the ventilator after the surgery but they do not say why. The critical care consult says that he has ‘post-operative ventilator dependence’. He maintains that the surgery was ‘uncomplicated’ and that the patient returned to the unit intubated and sedated. The intensivist then documents acute resp failure and says that they will attempt to wean but that it may be limited due to pain/peritonitis. She is extubated the same day. The following day the intensivist states that the patient was successfully extubated, has no current resp issues and is only on nasal cannula. She spends one day in the ICU and then is transferred to the floor.

This brought up the subject of post-op resp failure and when it should be coded. I know I have heard guidance that you should only code ARF after surg if the patient is vented more that 48hrs but that is generally in relation to cases where the patient is typically left vented post-op (CABG) which is not necessarily true for an ex-lap? In this case, I am not sure the patient really had resp failure. The patient had no resp issues prior to surgery, they were intubated for surgery and then extubated the same day without issue.

The question becomes, should this ARF be coded and/or should a query be placed for clarification?


If a query is required do you have a suggestion for options for a mult choice query?

maybe:
ARF as a complication of surgical procedure
ARF related to underlying issue (please explain)
Usual post-operative course without increased resource utilization
Other
Unable to determine

Thanks!!

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

kerryseekircher

Is there any evidence that they attempted to wean and failed-abg's, decreased o2 sats with adjustments in vent settings, etc.. That would be helpful in supporting the diagnosis. If the documentation is sketchy, I would definitely query for clarification especially given this is such a highly scrutinized diagnosis.
I have had cases where they document; acute resp failure; will keep intubated to ensure hemodynamic instability...in those cases, I don't feel the pt is in failure and they are more maintaining the pt on the vent in the event of decompensation (typically overnight!)
Thanks,
Kerry

Kerry Seekircher, RN, BS, CCDS, CDIP

Clinical Documentation Specialist Supervisor

Northern Westchester Hospital

400 East Main Street

Mount Kisco, NY 10549

Email: kseekircher@nwhc.net

Phone: 914-666-1243

Fax: 914-666-1013

katysuegood@gmail.com

Nope. I don't see anything that indicates trouble weaning. I think they maybe anticipated that he may be difficult to wean but he ended up not being. That's my guess....

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

kerryseekircher

You are probably right to go with your gut and avoid coding until further clarification. We have a Physician Advisor who speaks with the physicians directly if the diagnosis does not appear to have clinical indicators.
In my opinion, your query is compliant below-other than the fact that there would be no clinical indicators to back it up?
One of the acdis teachers for the cdi boot camp recommended asking the MD to document the diagnosis followed by 'as evidenced by' and 'treated with' in these cases; if he or she is unable to do so, then it should not be coded based on the guideline that it probably is not clinically significant.


Kerry Seekircher, RN, BS, CCDS, CDIP

Clinical Documentation Specialist Supervisor

Northern Westchester Hospital

400 East Main Street

Mount Kisco, NY 10549

Email: kseekircher@nwhc.net

Phone: 914-666-1243

Fax: 914-666-1013




-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, August 05, 2014 4:07 PM
To: Seekircher, Kerry
Subject: RE: RE:[cdi_talk] respiratory failure following trauma or surgery 518.51 and 518.52

Nope. I don't see anything that indicates trouble weaning. I think they maybe anticipated that he may be difficult to wean but he ended up not being. That's my guess....

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

catladyrn

I think one of the problems is that the intensivist needs to have intensity in order to bill for ventilator management, so they will hone straight in on "well, if they weren't on the vent, they wouldn't be able to breathe," and write respiratory failure.

I like and use the 48 hr rule, but would amend it somewhat to say it should be 48 hours beyond what you would normally expect for that type of surgery. Someone who is on a vent after having a hangnail removed might be in respiratory failure right off the bat, because they're not supposed to be on a vent, whereas someone who's had open heart might be expected to be ventilated for the first day or so depending on the acuity of the case, and would likely not be in true respiratory failure until they'd failed weaning for 48 hours. Giving them 48 hours allows for variation in individual circumstances and underlying conditions that affect extubation.

I've been known to bypass the acute respiratory failure game and go to postoperative respiratory insufficiency, which somehow seems easier for providers to swallow.

You certainly are allowed, per the practice brief, to query for documented conditions that lack clinical indicators. If you ask and they either can or can't give you the indicators, or repeat/revise their original diagnosis, that makes it easier for the coder in deciding whether to pick up the code. And the practice brief also directs you to escalate the conflict if you can't resolve it through the query process.

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

kbenson@uwhealth.org

We met with the intensivists who mostly care for the cardiothoracic surgical patients and came up with these parameters:

1. Documentation of respiratory failure for post-surgical patients.
- "Post-op ventilatory support" will be used to describe elective surgical patients who remain intubated in the immediate post-op period.
- "Post-op respiratory failure" will be used for patients who are not extubated within 48 hours of Anesthesia End Time.
- It is at the discretion of the intensivist how to describe patients re-intubated within that 48-hour window following a planned extubation.
- This may not apply to emergency cases, patients on mechanical ventilation pre-op, or trauma patients.

Kathy Benson RN, BSN, CCDS
Supervisor, Clinical Documentation Integrity
UWHealth University of Wisconsin Hospital & Clinics
600 Highland Avenue, Mail Code 7685
Office number F2/402
Madison, WI  53792
Phone: 608-890-5935