chronic resp failure / COPD exacerbation

leimapalo

A pt comes in for SOB, exp wheeze, elevated RR and diagnosed with COPD exacerbation. Pt has endstage COPD and is on home 02 and prednisone. Normally on 3L/NC but desatting to 79% on it, therefore 02 was increased to 5L overnight and placed on the usual COPD exac tx regimen. No ABG done on this admit. Query was placed to capture chronic resp failure, however, MD responded acute on chronic resp failure.

Would you guys capture this as true acute resp failure or was the resp sx/presentation in the disease process of COPD exac (meaning there was no acute component of resp failure, just chronic resp failure)?

Thanks!

sbeatty

I would query. The provider has to make the diagnosis. Ask him to document the assessment criteria to support his diagnosis and medical decision-making.

Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com
01923

leimapalo

@Sandy,

Are you suggesting a 2nd query? (his response to the 1st query was acute on chronic resp failure but I was only able to chronic)

sbeatty

yes

Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com

evanspx@sutterhealth.org

The message states: MD responded acute on chronic resp failure.

Code as acute on chronic respiratory failure - 518.84 - no 2nd query needed as MD made this response.

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

renmeyer@sbcglobal.net

Did the MD not document 'acute on chronic respiratory failure". Why would she need to put a second query for the acute. It's already documented by the MD.

katysuegood@gmail.com

I think the question posed here is:

The MD has now documented Acute on chronic resp failure but the CDI only see's clinical indicators of chronic. Do we have a 'diagnosis without clinical indicators' here and what is our responsibility to resolve this?
The new query brief suggests that a query may be indicated if you have a dx that is not supported by clinical indicators.

I don’t have an answer here but this is also something I am concerned about and have been since my first read of the new query brief. I am interested in how other facilities are handling these issues.

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

leimapalo

So the question really is - does acute resp failure occur in every COPD exacerbation or not? The pt is on chronic home 02 and prednisone. Presented with sx typical of COPD exac - SOB, rapid RR, wheeze, etc. Only increased his 02 requirement to 5L from his BL need of 3L.

The query was for the diagnosis for which the chr home 02/pred is prescribed for in the setting of his 'endstage COPD'. I was looking for chronic resp failure but MD responded "acute on chronic resp failure" in his prog notes. So it was a bit more than what I was aiming for, hence I'm curious how others are capturing this 2nd dx.

sbeatty

Because the writer actually referenced the absence of an ABG to support the acute. Will it hold up to scrutiny? My organization focuses on a quality medical record and I feel this is iffy. We would query a second time, but it would likely be verbal and then we could explain the problem. We are quite proficient with these conversations, as it is a delicate topic and we need for the physician to understand the audit consequences for the organization as well as himself. We are housed in quality rather than revenue cycle, so perhaps that explains the difference in approach.

Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com

leimapalo

@kathryn good:

thank you, that's exactly what i was asking

sbeatty

Exactly-well said, Katy.

Sandy Beatty, RN, BSN, CCDS
Director of Clinical Documentation Improvement
Community Health Network
1500 North Ritter Avenue
Indianapolis, IN 46219
317-355-2016
sbeatty@ecommunity.com

robert.hodges2

I agree completely. The record has to support the diagnosis.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

Clinical Documentation Improvement Specialist

Aleda E. Lutz VAMC

Mail Code 136

1500 Weiss Street

Saginaw MI 48602



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evanspx@sutterhealth.org

I understand ABGs are the Gold Standard, but it is not stated any place that ABGs "MUST" be performed to substantiatte the diagnosis of Acute Respiratory Failure. (It would be helpful to have the stated Respiratory Rate for the patient).

In any event, the scenario states the patient is on apparently placed on 5L/min Flow Rate which equates to a FI02 of 40% oxygen. Per 2012 CDI Pocket Guide, pg 40, "Any pt requiring FI02>40% almost certainly has acute respiratory failure regardless of p02 or Sp02".

Acknowledging ABGs are 'better', but also stated there are reasons a provider many not want to perform an ABG - if so, does this preculde the diagnosis if other clinical indicators support the decision.

Respiratory Failure in the Absence of ABG Testing

There may be instances in which a record may document “acute respiratory failure’ in the absence of ABG testing. The medical staff may chose not to perform ABG testing for a terminal patient that is DNR, for instance. While important, ABG testing should be the not be the sole determinant, a patient must also exhibit increased work of breathing – CC 2nd Qtr, 1990.

“Arterial blood gas determinations are only one of the supportive clinical findings. Other determinations must be taken into consideration before the diagnosis of respiratory failure is determined”… A patient with acute respiratory failure usually presents with increased work of breathing as typified by rapid respiratory rate, use of accessory muscles of respiration (such as intercostal muscle retraction), and possibly paradoxical breathing and/or cyanosis.”

* An oxygen saturation level of < 88% corresponds to a p02 50 mm Hg. Therefore, look for a corresponding oxygen saturation level in patients documented as having acute respiratory failure when ABG levels are not performed. Such a level in a patient with severe dyspnea at rest with a rapid respiratory rate and/or accessory intercostals muscle use and/or paradoxical abdominal motion may be experiencing acute respiratory failure.
* Source: AHIMA 2006 Audio Seminar Series, Sepsis, slide 66

If the record documents acute respiratory failure and the patient has severe hypoxemia with an O2 Saturation < 88% AND the patient exhibits other signs of respiratory failure, such as Tachycardia, Tahcypnema, Use of Accessory Muscles, Inability to speak in full sentences, and Cyanosis, it may be possible to advocate acute respiratory failure as a valid diagnosis. Use discretion as ABG testing is the “gold standard” in regards to the diagnosis of respiratory failure

Paul Evans, RHIA, CCDS, CCS, CCS-P

leimapalo

@Paul Evans:

RR 28, desaturation to 79% on pt's usual 3L.

evanspx@sutterhealth.org

I would code the physician's response as acute on chronic respiratory failure. The MD responded the pt had the acute on chronic respiratory rate and the RR was greater than 20. Pt placed on 5L with equates to FIO2 of 40%.


I would also check the H&P other signs of respiratory failure, such as Tachycardia, Use of Accessory Muscles, Inability to speak in full sentences, and Cyanosis.

It would make me more 'comfortable' to see the physician rationale to decline ABG testing - absence of ABG testing does not preclude the diagnosis, but does make it easier, IMO.


Per emedicine.medscape.com/article/167981 (updated 8/24/122

 Any patient on supplemental oxygen with a P02< 70 or Sp02< 92% may have acute respiratory failure.

 Any patient receiving supplemental oxygen with FI02 >32% may have acute respiratory failure if p02 is < 80 or Sp02< 95%
 Any patient requiring FIO2 > 40% almost certainly has acute respiratory failure regardless of the p02 or Sp02.

Thank you

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

don.cdi.rn@gmail.com

Any patient with a POx @ 79% (presuming an accurate reading, especially
with chronic 3L O2 not being adequate), along with clinical indicators
such as RR28, but would also like to see physician commentary about work
of breathing (position, retractions, speaking in phrases, labored,
etc.), I would see as supportive of being in acute respiratory failure.

I would defer to the original poster as far as the total content of the
record -- ie, narrative descriptions that paint the picture (either
way).

However, presuming the picture is painted toward the effort, we already
have 2 objective facts & treatment appropriate for a severe COPD pt, I
would have no hesitation in coding the a/c resp fail given what was
already described. The clinical indicators in my opinion would
support.

Don
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paxneros

leimapalo

Thank you all. Very helpful information!