Chronic Respiratory Failure

When I started in CDI I was taught that if a patient with COPD is on Home oxygen, it is appropriate to query for Chronic Respiratory Failure.  I am wondering how many of you query for that and if so, how do you go about querying for it?  I am always concerned that my query is leading and introducing new information since the doctor is not documenting respiratory failure prior to a query.


  • The CDI pocket guide for 2016 states:
    Diagnostic criteria:
    -hypoxemia of variable severity (often with baseline p02 <60 on RA)
    -elevated pC02
    -elevated bicarb level
    -normal pH

    It also has:
    The most important indicator of chronic resp failure is dependence on continuous home 02. Patients who qualify for home 02 have chronic resp failure and a baseline p02 <60 (Sp02 <91%).

    I think if the patient has a chronic lung disease severe enough to require continuous home oxygen that it is not leading. The docs do not think of this diagnosis unless it becomes acute. This is probably something we could all query for more frequently. It will be interesting to see what others have to say.
  • I also do not think it is leading and this is actually a big part of our job - we clarify with the doctors diagnoses that we find are supported by clinical data to make sure they get documented in the record.
  • Thanks Amy,
    I really need to get a pocket guide... I didn't have ABG for this particular stay, but it is documented that the pt is on up to 5L of O2 at home, so that should cover it
  • I love my pocket guide and highly recommend them to everyone. It's a good reference to have  since it includes clinical indicators/treatments for many conditions and also has the current coding guidelines. It is a bit pricey. I bought mine from a local vendor for hcpro and he gave me a 20% discount since we bought in bulk. Several of our staff wanted one too and it ended up costing $135 each with shipping.  I also like my friend's 2014 version (and even like some aspects of it better) and thought of buying an older on on ebay (since my hcpro connection said they do not sell old versions), but the 2014 version on ebay cost as much as the 2016 version!
  • Maybe I i'll wait and get the 2017 one since it's so late in the year
  •   Good idea. If you've lived this long without it, just wait and it will have the latest guidelines. I hope they keep churning them out year after year; a great little tool for us.   :)
  • I will be eager to try it out..Thank You!
  • While I work in a pediatric setting, I often clarify for chronic respiratory failure in infants/ children on home oxygen (infants with BPD discharged on home oxygen is the most common scenario). Often, MDs will document "oxygen dependent". I use any VBG/CBG results available (usually have normal pH, elevated PCO2) and serum CO2 (usually elevated). I LOVE my pocket guide, carry it with me on rounds every day. Glad to see more peds-specific stuff in the newest edition, hoping to see more. My copy is full of handwritten notes / tips for pediatric conditions.

    Jackie Touch
  • I agree completely with Amy. And I love the pocket guide too!
  • thanks everyone for your input!
  • I just came across your interesting discussion.   We query for chronic resp failure when the patient is on home oxygen, but often get the answer "COPD only" not "COPD with chronic respiratory failure"  Do you include the definition from the guide in your query, or how do you suggest we better query to get the "chronic respiratory failure" response without leading?  
    P.S.   I think I will invest in the 2017 Pocket Guide too!
  • mcmahons said:
    I just came across your interesting discussion.   We query for chronic resp failure when the patient is on home oxygen, but often get the answer "COPD only" not "COPD with chronic respiratory failure"  Do you include the definition from the guide in your query, or how do you suggest we better query to get the "chronic respiratory failure" response without leading?  
    P.S.   I think I will invest in the 2017 Pocket Guide too!
    What I tend to do with ex-premature infants with BPD/chronic lung disease is outline typical home treatment that BPDers receive (inhaled steroids, bronchodilator, and diuretic) and compare to the infant sent home on inhaled steroids, bronchodilator,  diuretic, and home oxygen 24/7 and ask if there is any clinical condition that requires one to go home on home oxygen while the other does not. This often initiates a lively discussion-sometimes MD agrees, sometimes not, but at least it gets everyone thinking and discussing the topic.

    Not sure if you can do the same with COPD...from what I remember when I worked the adult world years ago, treatment with oxygen is not required for all COPDers.

    Jackie Touch
  • I try to include the Home O2 evaluation when I query for Chronic Respiratory Failure.  It is not always done, but the documentation of the patient's Room Air sat and level of oxygen needed to maintain a sat of 90% is very helpful.

  • We query often for chronic respiratory failure when patients are on continuous home O2. We carry that further that if the patient is presenting with issues requiring increased FiO2 and other measures above and beyond what is normal maintenance care for the patient at home, we query for acute on chronic respiratory failure. We do include a table defining the difference between acute and chronic respiratory failure on the query.
  • Can someone please share their query?  We are having a difficulty time here. We are disagreeing as to how to word the query and when we do send it the response from MD is usually acute on chronic resp failure (it is one of the choices) which isn't clinically supported. I was asked to prepare a new query template and need you help. Here is our query:

    We need your assistance in determining the correct diagnosis for this patient. There is documentation from the record that this patient has a history of COPD and is on home oxygen @ ______L. Please provide the appropriate diagnosis that utilizes the use of continue oxygen therapy. Acute on Chronic Respiratory FailureAcute Respiratory Failure Chronic Respiratory Failure Hypoxemia Other - please specify Unable to determine This query will become part of the patient's medical record.

  • Our CDI staff does not use preformatted queries. If one or more of the options offered on a preformatted query is not clinically supported by the record (in this case acute respiratory failure) it could be argued that new information is being introduced into the medical record by offering options that are not supported by indicators, risk factors and/or treatment. It is labor intensive, but we personalize each query with indicators, risk factors and treatment specific to each patient and offer only options that are clinically supported. In the case of chronic respiratory failure, we offer indicators (ie home oxygen use 24/7, home vent, gases if available); risk factors (disease state resulting in failure); and treatment (continuation of home oxygen, continuation of vent at baseline home settings, etc).

    Jackie Touch
  • I have attached the resp fx template we use. Each time it is used, it is personalized by removing or adding content to meet the needs of the query  but this is the template we start with. As Jackie mentioned above,  we remove diagnoses that are not appropriate and we usually start with one of the 3 reasons for initiating the query and remove the others. We are currently in a discussion with others regarding the use of definitions/tables being included on the query. Some people say it is non-compliant if you do that but currently, we take the stance that if it supported by the clinical indicators, it is appropriate to do so.
  • i would suggest you work with a pulmonologist on staff to develop an organizational definition or diagnostic criteria for both acute and chronic respiratory failure. It likely would be very similar to that found in the Pocket Guide. use this defined criteria to spur queries as appropriate and roll it out  as education to your providers. This works well as it promotes consistency throughout the organization and lends credibility to your query as it was developed within your organization with the input of a pulmonologist. 

    There is a number of different criteria out there. often providers describe lung disease such as the GOLD classification grading. Teach providers to use the term chronic respiratory failure instead of 'end stage lung disease'. This is a diagnosis that is often missed, and is worth capturing. 
  • In reading the above, I am left with this question...can a patient have chronic respiratory failure and be treated with less than 24/7 continuous oxygen therapy? Can a patient be in chronic respiratory failure and be treated with steroids and nebs alone? In reading 3M CDI system reference it states the following "regardless of the amount of time on oxygen each day"

    3M Coding reference-CDI system reference

    Query Opportunity

    • Review the medical record documentation for the condition that requires the oxygen dependence, e.g., COPD, emphysema, acute-on-chronic systolic heart failure, chronic systolic heart failure, chronic respiratory failure. Query for clarification if condition is not documented.

    Clinical Documentation Concepts

    • Dependence on supplemental oxygen indicates the patient is on long term oxygen therapy. This can be reported regardless of the amount of time on oxygen each day (e.g., patient uses oxygen only at night). Additionally, although the patient might not be dependent on admission, review the record for need for home O2 at time of discharge.
    Thank you
  • Would love to get input from a Pulmonologist due to the complexity and apparently varying criteria.
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