Coding of Respiratory Failure

parrispa@musc.edu

We are having some conflict with coding 'respiratory failure' at our hospital. We are hearing that coding the 51881-acute respiratory failure- is impacting on quality issues and PORF RAC AUDITS. Has anyone changed their thinking process to coding respiratory insufficiency or other?
Curious to know if anyone else is having problems with this.
Thanks
Pam

Unknown

To piggyback on this great question, I am interested in the coding of postoperative/posttraumatic respiratory insufficiency and its impact on quality issues. I'm working on a surgery/trauma presentation and definitely would like more info on this prior to the presentation. Thanks, Joyce

afeighner

I am dealing with a chart right now that states respiratory failure and respiratory insufficiency in the postop period and gives no rational for either. The pt was never extubated/reintubated after surgery, the pt arrived straight from the OR suite intubated, and all the ABGS were acceptable. The pt was ventilated for 48 hrs and then extubated successfully. The coding clinic on this states that it is within normal limits to be intubated for up to 48 hrs postop. However many physicians documented the resp failure /insufficiency.....which is never mentioned in the discharge summary.

Amber L. Feighner RN MSN

evanspx@sutterhealth.org

Yes, postoperative failure, can be problematic for the following reasons:

1. Often not clinically valid, even though documented.

2. When coded, the POA indicator should be "N", thereby reporting the patient experienced respiratory failure AFTER admission and AFTER surgery - this has obvious quality connotations, none of them favorable.

3. Quite often, may be the sole MCC, thereby an obvious audit risk.


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:

Ø Physician documents it as not routinely expected or as a complication of the procedure
Ø Physician documents as due to another cause or due to medications or anesthesia
Ø 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