Critical care intensivist documentation

kbenson@uwhealth.org

We have been seeing physician documentation in our new Intensivist Service on cardiac surgery patients coming to the ICU postoperatively where they are stating “acute postop respiratory failure” and “cardiogenic shock" and "ABLA". In some instances, the patients are extubated and taken off the vent within several hours after arrival in the ICU. Documenting these conditions has posed a problem for our coders and our CDIs. We met with some of the group and, clinically, they feel the patients are in acute respiratory failure. The Cardiothoracic surgeons say that these diagnoses are an intregal part of these types of surgery. The Intensivists claim that they documented in this way in the institutions they came from. (Clevelend Clinic)

Is anyone seeing similar documentation in their facilities?
Did you have to create a definition as to when the acute respiratory failure can be used and coded in the postoperative period?

Our physicians want to make sure their documentation supports their charges while also not causing issues with the hospital’s documentation program. To that end, we are trying to gather information together for our next meeting with the physicians.

Any feedback would be most appreciated.

Thanks,

Kathy Benson RN, BSN, CCDS
Clinical Documentation Integrity Supervisor
kbenson@uwhealth.org

sannwoody

Coding the post op resp failure code can impact the hospital quality scores on healthgrades for sure as that code is a pt safety indicator. It is also a RAC target
Stephanie-
Sent from my iPad

katysuegood@gmail.com

This is what I was going to say.

Are they aware that this will impact their quality scores? Not just the overall hospitals but their individual complication rate?

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

debra.stewart@halifaxregional.com

Yes we have been discussing this a lot lately about making these post-op complications vs just conditions due to patient's co-morbidities prior to surgery. This does impact their quality scores and causes them to be looked closer at as surgeons. You can still and should use resp failure, but not always as a complication of surgery.
Deb
Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell

evanspx@sutterhealth.org

I do not think one should report any form of 'respiratory failure' unless further warranted in the particular situation described. It does not meet criteria.

The POA will be "N" and the code for respiratory failure following surgery will be reported.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.637.9002

evanspx@sutterhealth.org

katysuegood@gmail.com

I take this coding clinic to support Paul's statement. I don’t think it should be coded, even if stated unless mech vent is extended past the usual duration.

That is my understanding at least.

We have the opposite problem though ;-)

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Respiratory failure following trauma and surgery

Coding Clinic, Fourth Quarter 2011 Pages: 123-125 Effective with discharges: October 1, 2011

Related Information
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.



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

kbenson@uwhealth.org

They are now after we met with them. However, most of these surgeries far into MDCs 4 and 5 which makes them exclusions in PSI 11.