Resp Failure and AHRQ
Hello All!
I am trying to work out some comprehensive education for our CDI and Coding team regarding Respiratory Failure. I will be including Acute Resp Failure, Chronic Resp Failure, and Post-op Resp Failure in this discussion. Of course, I am stuck on Post-op resp failure issues. I have read the coding clinics and other resources I found on ACDIS and I understand the post-op period and all that. I have two questions:
1. What kind of documentation do you (or your facility) expect in order to tie the resp failure to surgery? I understand that Resp failure should not be assigned if it is routine for the procedure. I also know that the ICD-9 index suggests that an explicit link to surgery must be made to assign a complication. Since there are discrepancies regarding use of the term “Post-op†(link or time frame?), do you expect further documentation to establish a link before coding Post-op ARF or do you code Post-op ARF if the resp failure occurs after surg (or is extended past the usual surgical window) regardless of whether the MD specifically states that the conditions are linked?
2. Am I correct in my understanding that 518.51 and 518.53 are currently included in PSI11 for AHRQ and that 518.51 and 518.84 are no longer tracked for these purposes? I am looking at the website (pg 15 of the file below) and it appears that this is what happened in March 2012, but I want to be sure I am providing the correct information.
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/PSI_Changes_4.4.pdf
Anything else that anyone would like to weigh in on would be greatly appreciated as well.
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
I am trying to work out some comprehensive education for our CDI and Coding team regarding Respiratory Failure. I will be including Acute Resp Failure, Chronic Resp Failure, and Post-op Resp Failure in this discussion. Of course, I am stuck on Post-op resp failure issues. I have read the coding clinics and other resources I found on ACDIS and I understand the post-op period and all that. I have two questions:
1. What kind of documentation do you (or your facility) expect in order to tie the resp failure to surgery? I understand that Resp failure should not be assigned if it is routine for the procedure. I also know that the ICD-9 index suggests that an explicit link to surgery must be made to assign a complication. Since there are discrepancies regarding use of the term “Post-op†(link or time frame?), do you expect further documentation to establish a link before coding Post-op ARF or do you code Post-op ARF if the resp failure occurs after surg (or is extended past the usual surgical window) regardless of whether the MD specifically states that the conditions are linked?
2. Am I correct in my understanding that 518.51 and 518.53 are currently included in PSI11 for AHRQ and that 518.51 and 518.84 are no longer tracked for these purposes? I am looking at the website (pg 15 of the file below) and it appears that this is what happened in March 2012, but I want to be sure I am providing the correct information.
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/PSI_Changes_4.4.pdf
Anything else that anyone would like to weigh in on would be greatly appreciated as well.
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
Comments
GOOD MORNING! DIFFERENT PLACE, SAME ISSUE!~
I CAN ADD THAT WHEN OUR CONSULTANT GROUP WAS HERE IN JULY THEY ADVISED TO ADD "POST OP PULMONARY INSUFFICIENCY" TO OUR "RESP FAILURE" QUERY". THEY DID NOT HOWEVER GIVE US ANY INDICATORS. IN LOOKING AT THE ACDIS SIGHT REGARDING THAT SAME ISSUE, (THERE IS A POST REGARDING POST-OP PULM INSUFF), THE DEFENITION USED IN THE POST IS "A DECREASE IN NORMAL PULM FUNCTION DUE TO TRAUMA TO THE THORACIC CAVITY AND/OR SURGICAL INTERVENTION"......
The guidelines THEY asked their physicians to consider are as follows:
Has pulmonary/critical care medicine been consulted?
Has the patient experienced increased oxygen requirements over time?
Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
Are chest x-rays being frequently monitored?
Are pleural effusions being monitored or treated?
So WE TOO ARE RESEARCHING THE SAME ISSUES AS YOU KATY...WILL BE INTERESTING TO SEE WHAT COMES UP FOR THIS TOPIC!
Juli Bovard RN CCDS
Regional Health
Have you seen the ACDIS article "documenting the term insufficient is insufficient"? My coding manager and I were just discussing these issues yesterday (she is a part of our CDI team) and then I came across this artivle this AM. Dr. Gold suggests that we should not be encouraging the documentation of resp insufficiency under ANY circumstances. Interesting, right?
http://www.hcpro.com/acdis/details.cfm?content_id=271879
One of the things I have been struggling with in regards to respiratory failure is that there have been several recent changes and code additions, so it can be difficult to filter through and determine which guidance is relevant and/or most appropriate currently.
I would love more input from CDS' about whether they are querying for "insufficiency".
Additionally, I would appreciate input from Coders (or CDI's with this knowledge) about what their coding team requires in the documentation before they assign a post-op resp failure/insufficiency.
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
Juli
We were discussing this yesterday with coders as well. Some time ago we decided as a group to code the word "post op" as an indication of time as opposed to complication. We decided the MD needs to make the link before a complication will be coded. If the CDS sees that a complication did arise from surgery but that MD is not calling it as such, we will query the MD to verify if "xxxxxx" is a complication of surgery or inherent in the surgery. However, we listened to a webinar that gave us a conflicting opinion. We would also appreciate hearing how the majority of CDI teams are addressing this.
As for resp insufficiency (ARI), I am on the fence with this and need more clarification. I read Dr. Gold's article several months ago. I presented it immediately to our Coding manager who stated that Dr. Gold does not cite coding clinic, coding guidelines, or other research based guidelines in his article. He stated it is his "opinion". So I have been looking for something definitive. In my search, I found some references in the CDI pocket guide on page 43 regarding postop resp. insufficiency. But, I did not find a good definition of when to use ARI.
Coding clinic, 1988, Third Quarter states "when the terms of pulmonary or respiratory insufficiency are used by the physician, it is usually not in a setting of impending life-threatening conditions or the need for endotracheal intubation (as with ARDS)". Is there any guidance more current?
Can any of the Coding Gurus help me out with understanding if this means ARI is a viable term in regards to resp status even regardless of post op status. It is a code-able cc.
Thank you in advance.
-Jane
-Jane
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
I am glad I am not alone. Strength in numbers! We have the same issue. When it comes to other surgical complications, the coders have been provided guidance that the MD must specifically link the complication with the surgery. This mean more than just "post-op" as we also recognize that this term is often used to define a time, not causation. We have also encouraged a query if there is suspicion that the surgical procedure was the cause of the "complication". However, our complication rate is very low because (as I am sure you know) when you present a query asking if there is a link between the surgery and the complication, they are quick to respond with a "no" in most cases. If we are being consistent, we should also be querying in this case. However, if keep reading snippets of information that seemt o suggest that this is the appropriate code to use for post-op Resp failure unless the failure is attributed to a alternate issue. Also, coders may not recognize the importance of querying in these circumstances because they may not consider it a "complication" code, though it is seen as such for HeathGrades (at least this is my understanding that healthgrades is looking at this code, correct?) and other such organizations.
I agree that Dr. Golds article lacks and "coding backup" since there is no guidance on this issue that I have seen from coding sources. However, It does make me hesitate to add this as a query option (as Juli's consultant has recommended) as I think it may later become a RAC issue if this dx is not firmly backed up with clinical data supporting it. As it stands, I think that if coders see it in the documentation, they likely need to code it as such, but I'm not sure about pushing MD's to document it. Does that make sense?
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
My opinion is that a coder is, indeed, going to ordinarily code precisely what is documented. (This is our 'duty' - HOWEVER, given the ongoing need for a coder to 'vet' diagnoses for reasons of proper reimbursement, compliance, and compliance, I believe more precise industry standards should be used and adopted by all).
Given that the diagnosis is often stated and charted during the recovery period following Mitral Value Repair or CABG in a stable patient w/o an indication of a cardiopulmonary decompensation and is only recovering from anesthesia on a vent during the recovery period, it will be questioned by 3rd parties if coded routinely.
What do to do?
Consider that at a large facility, we may not be able to get the staff to 'stop' documenting the condition - the habit is deeply ingrained.
You could (should):
1. Continue to educate the staff regarding the use of the term and the consequences upon the surgeon's profile as well as the facility.
2. The Coding Mgr should discuss this with the proper executives at the facility and inform them the condition will not be coded, even if documented, unless it qualifies as an additional condition per the Official Guidelines.
The P&P for Coding would be something such as below - I have not polished this as I am not the Coding Mgr, but I think the reasoning is sound.
Postoperative Respiratory Failure/Insufficiency
Many physicians document “acute respiratory failure/insufficiency” in the postoperative period. 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 condition is induced, 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.
HIM will not ‘code’ postoperative respiratory failure/insufficiency if there is not clinical support for this decision – ‘best practice’ would be to state in our notes section that “518.5X noted”.
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
The condition requires consultation and or additional treatments for not ordinarily expected during the period of recovery
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
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
HIM will not ‘code’ postoperative respiratory failure/insufficiency if there is not clinical support for this decision – ‘best practice’ would be to state in our notes section that “518.5X noted”.
It ‘may’ be appropriate to code if:
1.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
2. Mechanical Ventilation is required for more than 48 hours after surgery or reintubation with mechanical ventilation is performed
3. The condition requires consultation and or additional treatments for not ordinarily expected during the period of recovery
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
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
It is interesting that the focus is not always on getting the diagnosis, but on getting documentation of the clinical support for the diagnosis.
Renee
Linda Renee Brown, RN, CCRN, CCDS, CDIP
One case in point - a coder 'must' code the term postoperative ileus as a complication.
However, other conditions termed as postoperative are not defaulted as a 'complication'
I agree it would be 'best' not to encourage staff to use this term - in my mind, it applies only to a time table, rather than establishing cause & effect - but, be aware coders are 'forced' to use certain codes for complications with such terminology. Given the tremendous time crunch faced by coders, don't expect a coder to query every time this term is charted - it won't happen in the 'real world'.
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
Briefly, one real issue for our industry is also that the 518.5X should be reported with a POA of "NO" and may result in the 'sole' MCC for many such cases. If I worked for the RAC, I would target such cases.
Many times, the patient is perfectly tuned up prior to a planned admission for a CABG or MV, making the reporting of a valid MCC unlikely for a great many such cases.
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
I think this decision stems from complications such as Post-op hemorrhage and post-op ileus.
The issue that I see with this process is that the MD very rarely will explicitly respond to a query stating that they did indeed have a complication related to surgery. I worry that we are undercoding these dx. The coder is coding correctly based on the query response, however, I am not always sure about accuracy of the record.
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
I hope you saw Paul's recent post in a different conversation thread --
his attachment is absolutely wonderful!! (the thread was titled
respiratory failure following trauma or surgery 518.51 and 518.52).
We will query for insufficiency. We will also specifically query to
clarify the term 'post-op' when it appears to be a temporal indication,
not cause & effect. ESPECIALLY when it appears to be the expected
course of events. Usually don't have a significant problem however with
patients in the normal routine flow being described as post-op
respiratory failure/insufficiency. If anything, it is not used quite
enough.
Don
evanspx@sutterhealth.org
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