post op VDRF

vanessa.falkoff

Hi everyone,

Does anyone have an article or resource they could recommend for a conversation with a physician who has started consistently documenting post op VDRF the day of surgery?
Thanks!

Vanessa Falkoff RN
CDI Coordinator
UMC Southern NV

vdavis2

This is Dr. Gold's soapbox! Refer back to his discussion on ACDIS quarterly conference calls and his articles. Brian Murphy may be able to link you to some of Dr. Gold's work.

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

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evanspx@sutterhealth.org

My thoughts are that many MDs will document Respiratory Failure immediately after something such as MV replacement, and the coding of same is questionable. From my perspective, each HIM dept should have a policy that the code for respiratory failure in such situations will not be coded unless other indications are charted. Complicated topic -


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

vanessa.falkoff

Thank you Paul ...may you be eternally blessed for your generosity!

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054