Coding Ventilator managment
What is the proper "diagnosis" to be used by the critical care pulmonologists managing a ventilator on a patient that comes back from the OR after a difficult surgery that may require them going back to the OR. The patient is not in respiratory failure but is being kept on the ventilator for a medical resting period or the high probability of a return to the OR within 24 hours. Our pulmonology/critical care docs are documenting " Acute respiratory failure: Iatrogenic ventilation." They have agreed it is not respiratory failure but medical management. How should they be documenting this and how should we be coding it?
Comments
The proper diagnosis would be the condition that lead to the surgical procedure, not 'postoperative respiratory failure', unless it is truly present.
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.
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
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
Query:
On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has "P.O Respiratory Failure"
Please clarify the nature of the patient's respiratory status occurring in the post-operative period. You may answer this query by marking the checkbox(es) below or using free text at the ( * ) if appropriate. Provider Query Response:*The patient is on mechanical ventilator for a routinely expected time frame to assure competency of the upper airway as part of normal recovery, as is usual and customary for this procedure, requiring no unusual or unexpected resources Respiratory failure is present as a post-operative complication of surgery on DATE ***, as evidenced by an unanticipated need to extend mechanical ventilation and/or gas exchange that is physiologically required to prevent or treat decompensation Respiratory failure is present and is related to patient’s other conditions / co-morbidities, or other non-surgical cause – please specify* Unable to determine
The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expectedAt our facility, we are not coding the Acute Respiratory failure if the patient is kepted on the vent to protect the airway and may possibly return to surgery.
Hello,
I had a record recently where the patient was on the ventilator longer than 48 hour after Transoral Laser Resection of right Base of tongue Lesion, Staged right neck Dissection. Patient returned to OR 4 days due orapharyngeal wound hemorrhage. would you code ventilator dependent?
Ventilator dependent is not a diagnosis. Given your staff has stated' there is no ARF, you may code the PCS codes for the MV, but not respiratory failure as it is not present.
REF:
VOLUME 29 THIRD QUARTER NUMBER 3 2012, Page 21 Mechanical Ventilation for Airway ProtectionQuestion: 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.
Coding advice or code assignments contained in this issue effective with discharges September 15, 2012Paul Evans, RHIA, CCDS, CCS, CCS-P