airway protection/resp failure
Hi all,
I am wondering how you handle intubation for airway protection when Acute Resp failure IS documented. The only guidance I know about airway protection is when ARF is NOT documented:
Mechanical ventilation for airway protection
Coding Clinic, Third Quarter 2012 Page:21 Effective with discharges: September 15, 2012
Question:
A patient presents to the Emergency Department (ED) due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the intensive care unit (ICU) and documents that the patient was intubated for airway protection because of the drug overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the following next day. Can the coder assume that the patient was in respiratory failure and report code 518.81, Acute respiratory failure, based on the fact that the patient was intubated and placed on mechanical ventilation for airway protection?
Answer:
Do not assign code 518.81, Acute respiratory failure, simply because the patient was intubated and received ventilatory assistance. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated (e.g., respiratory failure) needs to be clearly documented by the provider.
However, we sometimes get documentation of airway protection in cases where we are also documenting acute resp failure. Sometimes it is clear that the patient really did have resp failure and it seems the physician is using the term 'airway protection' without clear reason. But in other cases of encephalopathy, seizures, overdose, etc we truly are intubating for airway protection because the patient is unable to clear secretions, is bradypneic, etc. In those cases where intubation was for airway protection but the provider IS documenting Respiratory Failure, do you:
1. Code resp failure
2. Do NOT code resp failure
3. Reverse query/clinical indicator since patient does not meet definition of ARF.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I am wondering how you handle intubation for airway protection when Acute Resp failure IS documented. The only guidance I know about airway protection is when ARF is NOT documented:
Mechanical ventilation for airway protection
Coding Clinic, Third Quarter 2012 Page:21 Effective with discharges: September 15, 2012
Question:
A patient presents to the Emergency Department (ED) due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the intensive care unit (ICU) and documents that the patient was intubated for airway protection because of the drug overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the following next day. Can the coder assume that the patient was in respiratory failure and report code 518.81, Acute respiratory failure, based on the fact that the patient was intubated and placed on mechanical ventilation for airway protection?
Answer:
Do not assign code 518.81, Acute respiratory failure, simply because the patient was intubated and received ventilatory assistance. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated (e.g., respiratory failure) needs to be clearly documented by the provider.
However, we sometimes get documentation of airway protection in cases where we are also documenting acute resp failure. Sometimes it is clear that the patient really did have resp failure and it seems the physician is using the term 'airway protection' without clear reason. But in other cases of encephalopathy, seizures, overdose, etc we truly are intubating for airway protection because the patient is unable to clear secretions, is bradypneic, etc. In those cases where intubation was for airway protection but the provider IS documenting Respiratory Failure, do you:
1. Code resp failure
2. Do NOT code resp failure
3. Reverse query/clinical indicator since patient does not meet definition of ARF.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
I am primarily seeing this In patients brought into the ED, not post-op patients. These are patients who are intubated in ED because they are unable to protect their airway due to overdose, seizures, obtundation, etc. They document acute resp failure and say they are intubating for airway protection.
I don’t see this in our post-op patients. Probably because they don’t want the complication code ;-)
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 08, 2016 2:48 PM
To: Kathryn Good
Subject: re:[cdi_talk] airway protection/resp failure
Check it out. You offer the doc the option of identifying the condition as post-operative respiratory failure, a complication of the surgery that the surgeon caused and please provide the disease that is causing the postoperative respiratory failure OR the doc is providing ventilator management in a complex patient who is being maintained purposefully on the vent after heart surgery or in a staged operation (bowel ischemia) or a morbidly obese patient that you want to AVOID going into acute respiratory failure, etc.
Dr. Gold
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Very informative...I've often wondered who coaches ICU physicians to document in this fashion?
[cid:image001.png@01D17943.6F991C50]
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 08, 2016 1:48 PM
To: Evans, Paul
Subject: re:[cdi_talk] airway protection/resp failure
Check it out. You offer the doc the option of identifying the condition as post-operative respiratory failure, a complication of the surgery that the surgeon caused and please provide the disease that is causing the postoperative respiratory failure OR the doc is providing ventilator management in a complex patient who is being maintained purposefully on the vent after heart surgery or in a staged operation (bowel ischemia) or a morbidly obese patient that you want to AVOID going into acute respiratory failure, etc.
Dr. Gold
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
[cid:image001.jpg@01D1794B.E5A41960]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 08, 2016 3:01 PM
To: Evans, Paul
Subject: Re: [cdi_talk] airway protection/resp failure
It's often the business managers at the hospitals who "learn" that you need an organ failure in order to bill critical care which is totally inappropriate for reversal from anesthesia or for monitoring a patient after a stroke or head trauma.
Robert S. Gold, MD
CEO DCBA,Inc
4611 Brierwood Place
Atlanta, GA 30360
On Mar 8, 2016, at 5:04 PM, CDI Talk wrote:
Dr. Gold
Very informative...I've often wondered who coaches ICU physicians to document in this fashion?
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, March 08, 2016 1:48 PM
To: Evans, Paul
Subject: re:[cdi_talk] airway protection/resp failure
Check it out. You offer the doc the option of identifying the condition as post-operative respiratory failure, a complication of the surgery that the surgeon caused and please provide the disease that is causing the postoperative respiratory failure OR the doc is providing ventilator management in a complex patient who is being maintained purposefully on the vent after heart surgery or in a staged operation (bowel ischemia) or a morbidly obese patient that you want to AVOID going into acute respiratory failure, etc.
Dr. Gold
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
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