Acute Pulmonary Insufficiency

When discussing persistence of greater than expected oxygenation problems beyond 48 hours in a post op extubated patient I inquire about whether or not the diagnosis of Acute Pulmonary Insufficiency is applicable with physicians and they simply state they have never heard of the term and or have never seen the definition of it.  Physician’s often use the term ‘Insufficiency’ loosely in there documentation except in the case of Acute Pulmonary Insufficiency. We often see documentation of adrenal insufficiency, arterial insufficiency, acute coronary insufficiency, pancreatic insufficiency, acute renal insufficiency, acute respiratory insufficiency, vertebro- basilar insufficiency etc. 

Let us split the hairs between failure and insufficiency. Merriam Webster dictionary defines failure as “a state of inability to perform a normal function” where the word perform is defined as: to carry out an action. In practice Respiratory Failure is defined as: the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory failure is defined as a P/F ratio < 300, a PaO2 value of less than 60 mm Hg while breathing room air or a PaCO2 of more than 50 mm Hg.

Respiratory is defined as: of or relating to respiration which is movement of gases (as oxygen and carbon dioxide) into and out of the lungs. 

Merriam defines insufficiency as” inability of an organ or body part to function normally” where function is defined as any group related actions contributing to a larger action. Pulmonary is defined as: of, relating to, affecting, or occurring in the lung. 

So what could cause the lungs not to function normally (be insufficient) in the post op patient? Why the prolonged oxygen therapy without a diagnosis? Well we all learned this stuff years ago in med school. The most common causes of course are atelectasis and lung edema. But many other issues exist as well. Reduced tidal volume of up to 50% depending the location of the incision (thorax, upper abdomen).Reduced lung expansion from post op pain, supine position, abdominal distention, sedatives and narcotics. Increased ventilation rate secondary to anxiety leads to loss of normal periodic hyperinflation. Compromised airway defenses secondary to loss of normal cough reflex, decreased ciliary activity and accumulation of secretions. Problems related to laparoscopic surgery include diaphragmatic splinting from pneumoperitoneum. Another issue is the (SIRS) systemic inflammatory state from the trauma of surgery itself in which circulating inflammatory mediators cause edema in the lung parenchyma. Variables predictive of postoperative pulmonary insufficiency include active cigarette smoking, baseline COPD, and cardiac, renal, or bleeding complications. 

CMS has provided an ICD 10 CM code to capture the condition but it needs to be documented as “Acute Pulmonary Insufficiency” for the code to be assigned. The code for Acute Pulmonary Insufficiency was created to capture the cost of treating those patients requiring greater than expected LOS or use of oxygen for hypoxia post operatively. J95.1 Acute Pulmonary Insufficiency (coder will use this code in thoracic surgery cases) J95.2 Acute Pulmonary Insufficiency MCC (coder will use this code in non-thoracic surgery cases).

So if you’re surgical patient is not progressing as expected due to the inability of 1 or both lungs to function normally consider the diagnosis of acute pulmonary insufficiency in your documentation to explain this delay in discharge.

Comments

  • Pulmonary Insufficiency is a real condition and it is sited in several medical textbooks.
    In Clinical Anesthesia, 5th Edition Copyright ©2006 Lippincott Williams & Wilkins Pg 434 Microaggregates have been implicated in the pathogenesis of pulmonary insufficiency and the development of ARDS, which often follows large volume transfusions (defined as >10 to 12 units in 24 hrs). Pg 1918 despite advantages in cardiac surgery and perfusion technology, the deleterious effects of CPB are well documented. These include stroke and neurocognitive defects, renal failure, pulmonary insufficiency, coagulopathy, and activation of a systemic inflammatory response.
      
    In Johns Hopkins Textbook of Cardiothoracic Surgery 2014 Pg 68 Lesions that replace functional lung parenchyma can also cause pulmonary insufficiency. Pg 120 Predictably, pulmonary insufficiency was an issue and 21 percent of patients required at least one reintubation, tracheostomy was necessary in 8.2, and 5. 1 percent could not be weaned Pg 122 Cardiac dysrhythmias, pneumonia, and pulmonary insufficiency constitute the most common causes of morbidity, just as with LVRS.

    In 2013 Principles and Practice of Cardiothoracic Surgery Copyright © 2013 InTech Pg 62 Post thoracic surgery especially in resections intravenous fluids are given in reduced amounts to prevent pulmonary insufficiency. Postoperative pulmonary insufficiency occurs because of infection, inability to clear secretions or edema around day 2 or 3, to prevent these from happening attention should be given to physiotherapy, bronchodilators, restriction of intravenous fluids and tracheal toilet. Chest physiotherapy includes deep breathing and coughing exercises and incentive spirometry. Pulmonary insufficiency is more common in patients have low FEV1.

    In 2012 Cardiac Surgery in the Adult Lawrence H. Cohn, MD Pg 267 Even mild residual neuromuscular blockade contributes to pulmonary insufficiency by compromising mechanics of breathing and decreasing negative inspiratory force, vital capacity, tidal volume, and the ability to generate an effective cough.

    In 2011 Springer : CT Surgery in the Elderly Pg 392 Multivariate analyses by Williams et al., who studied a group of 300 octogenarians who underwent isolated coronary artery bypass, revealed that preoperative renal dysfunction (creatinine >2.0 mg/dL), pulmonary insufficiency, and postoperative sternal wound infection were strong predictors of hospital mortality.

    In 20013 Trauma 7th edition pg 485 In patients without a pneumothorax or with a pleural symphysis, insertion of a large-bore needle into the lung in an intubated patient can contribute to fatal systemic air embolism and also cause a pulmonary hematoma with subsequent pulmonary insufficiency.  These conditions are the basis for the traditional A-irway, B-reathing, C-irculation of resuscitation. Infection, sepsis, pulmonary insufficiency, and other functional impairents may occur secondarily, and any or all contribute to the decision to operate and when. Pg 1035Assessing specific pulmonary mechanics can significantly aid in diagnosing and treating a patient’s sudden or progressive pulmonary insufficiency.Pg1040 TCPV is useful in patients with progressive pulmonary insufficiency or ARDS, while also meeting acute respiratory distress syndrome network (ARDSNet) criteria so long as the set driving pressure and PIPs are below 30 cm H 2O pg1113 Since pulmonary function generally shows little improvement with fluid restriction during the initial 24 hours of a massive septic insult, the pulmonary insufficiency appears to result from the sepsis, per se, rather than a PV overload.

    In 2012 Textbook of Critical Care Pg 75 TRALI presents with dyspnea and bilateral pulmonary edema during or within up to 6 hours of a transfusion, with no other risk factors to explain its development. It must be distinguished from pulmonary insufficiency due to circulatory overload, where the central venous pressure and pulmonary artery wedge pressure would be elevated. Pg 701 ECMO is generally used in the adult population for periods of 1 to 10 days when there is marked concomitant pulmonary insufficiency and cardiac failure. The use of ECMO in the adult population for reasons other than primary cardiac failure with secondary pulmonary insufficiency has limited advantages over conventional therapies Pg 704 The hallmarks of cardiogenic shock are low cardiac output, hypotension, peripheral vasoconstriction, cold extremities, poor urine output, and altered mental status. As the pathophysiologic state progresses, pulmonary insufficiency and pulmonary edema ensue. Pg 705 The mode of mechanical support used for cardiogenic shock is determined by a number of factors. The first is the degree of pulmonary insufficiency. If there is pulmonary failure with a very large alveolar-to-arterial oxygen gradient on maximal ventilatory support, ECMO support is indicated. A small percentage of ECMO patients in this setting will recover, some will require VAD placement as a bridge to transplantation, fewer still will bridge to VAD and then to recovery. If the degree of pulmonary insufficiency is limited to pulmonary edema that is likely to recover with adequate cardiac output, patients should undergo VAD placement directly.

    In 2008 Critical Care current diagnosis and treatment Pg 740 The current treatment of inhalation injury is primarily supportive because no specific agent has been identified that minimizes the severity of the insult. The aim of treatment, therefore, is to correct the underlying pulmonary insufficiency while minimizing further iatrogenic pulmonary insults. The amount of intervention required is guided by the severity of pulmonary insufficiency. Pg749Inhalation of aerosolized chemicals may produce pulmonary injury and systemic toxicity, thus requiring accurate diagnosis and aggressive treatment. Varying degrees of pulmonary insufficiency may be agent-specific and manifested by severe airway edema formation, mucosal sloughing, and bronchospasm. Systemic toxicity through pulmonary absorption may occur; thus the causative agents must be clearly identified to ensure appropriate diagnostic and treatment strategies. The degree of pulmonary support required is determined by the severity of pulmonary insufficiency.

    In 2014 Common Problems in Acute Care Surgery, Chapter 8 Page 109 and 2009 Comprehensive Vascular and Endovascular Surgery Chapter 33, Page 569 pulmonary insufficiency is mentioned throughout these chapters.
  • We are being asked by a consultant company to begin querying for acute pulmonary insufficiency following surgery on pts who are requiring O2 and have a GMLOS longer than expected without an obvious reason why but are still on O2.  Are others querying for this diagnosis?
  • Has anyone established clinical criteria for the diagnosis of Acute Pulmonary Insufficiency or created a policy that they are willing to share?
  • Has anyone established the condition pulmonary insufficiency found in many textbooks , including trauma and anesthesia with the ICD coding of pulmonary insufficiency and coding guidelines of such?

    We are tossing this one back and forth and have not formulated an exact plan on how to go about it...


  • When discussing persistence of greater than expected oxygenation problems beyond 48 hours in a post op extubated patient I inquire about whether or not the diagnosis of Acute Pulmonary Insufficiency is applicable with physicians and they simply state they have never heard of the term and or have never seen the definition of it.  Physician’s often use the term ‘Insufficiency’ loosely in there documentation except in the case of Acute Pulmonary Insufficiency. We often see documentation of adrenal insufficiency, arterial insufficiency, acute coronary insufficiency, pancreatic insufficiency, acute renal insufficiency, acute respiratory insufficiency, vertebro- basilar insufficiency etc. 

    Let us split the hairs between failure and insufficiency. Merriam Webster dictionary defines failure as “a state of inability to perform a normal function” where the word perform is defined as: to carry out an action. In practice Respiratory Failure is defined as: the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory failure is defined as a P/F ratio < 300, a PaO2 value of less than 60 mm Hg while breathing room air or a PaCO2 of more than 50 mm Hg.

    Respiratory is defined as: of or relating to respiration which is movement of gases (as oxygen and carbon dioxide) into and out of the lungs. 

    Merriam defines insufficiency as” inability of an organ or body part to function normally” where function is defined as any group related actions contributing to a larger action. Pulmonary is defined as: of, relating to, affecting, or occurring in the lung. 

    So what could cause the lungs not to function normally (be insufficient) in the post op patient? Why the prolonged oxygen therapy without a diagnosis? Well we all learned this stuff years ago in med school. The most common causes of course are atelectasis and lung edema. But many other issues exist as well. Reduced tidal volume of up to 50% depending the location of the incision (thorax, upper abdomen).Reduced lung expansion from post op pain, supine position, abdominal distention, sedatives and narcotics. Increased ventilation rate secondary to anxiety leads to loss of normal periodic hyperinflation. Compromised airway defenses secondary to loss of normal cough reflex, decreased ciliary activity and accumulation of secretions. Problems related to laparoscopic surgery include diaphragmatic splinting from pneumoperitoneum. Another issue is the (SIRS) systemic inflammatory state from the trauma of surgery itself in which circulating inflammatory mediators cause edema in the lung parenchyma. Variables predictive of postoperative pulmonary insufficiency include active cigarette smoking, baseline COPD, and cardiac, renal, or bleeding complications. 

    CMS has provided an ICD 10 CM code to capture the condition but it needs to be documented as “Acute Pulmonary Insufficiency” for the code to be assigned. The code for Acute Pulmonary Insufficiency was created to capture the cost of treating those patients requiring greater than expected LOS or use of oxygen for hypoxia post operatively. J95.1 Acute Pulmonary Insufficiency (coder will use this code in thoracic surgery cases) J95.2 Acute Pulmonary Insufficiency MCC (coder will use this code in non-thoracic surgery cases).

    So if you’re surgical patient is not progressing as expected due to the inability of 1 or both lungs to function normally consider the diagnosis of acute pulmonary insufficiency in your documentation to explain this delay in discharge.

    I am assuming you are a physician or surgeon. Can you provide your credentials, I want to refer this information to our CTS and I know they will want to know your credentials.
  • edited February 28

    Remember the point of coding: To capture in as few codes as possible the entire patient story.

    From a coding/reporting stand point, Respiratory Insufficiency or Failure (depending on the severity and providers judgement) may not be reported during the normal post-op recovery period as the definition is a RESOURCE UTILIZATION definition and NOT a CLINICAL definition.  Therefore the average cost of resources used for routine post-op recovery is already being reimbursed via the surgical DRG. Please be aware this is in stark opposition to E&M reporting guidelines, which seeks to capture the work of the provider and not the resource utilization of the facility.  I am aware that some providers are seemingly indiscriminately making every patient have postoperative respiratory insufficiency as they attempt to capture the provider work of managing the ventilator.  However you must realize the reporting requirements for the inpatient hospital stay are very different than the reporting conventions for capturing physician resource utilization.




    Again, since this is a resource utilization definition and not a clinical standard, the diagnosis of respiratory Insufficiency becomes reportable when the post-operative care exceeds the expected or average post op recovery services. 

    Also ask yourself: What is the significant clinical difference between a patient on a vent for 47.5 hours and a patient on a vent 48 hours?  Rhetorical , there isn't any and a 48 hour period is arbitrary from a clinical standpoint...though it may be relevant as an average cost standard. 

    Be that as it may, a newer coding clinic (1st Q 2017) in regards to counting ventilator hours deviates from the past time period of 48 hours and simply says vent hours are separately reportable when a patient is on the ventilator longer than expected for a given procedure . The exact verbiage they give us is an "extended period".

    Since a teenager who received care for an open tibial fracture repair is likely to be on a vent MUCH shorter than an 80 year old morbidly obese patient with end stage COPD who underwent a heroic AAA rupture repair, the number of hours as a measure is likely somewhat worthless and prone to be highly variable from one patient to another.

    In coding, if the extensive respiratory resource utilization is not understood from the reported ICD 10 procedure code then additional codes become necessary to fully tell the patient story.   Therefore, a post-op respiratory diagnosis is reportable when additional resources are expended . 

     This can often be identified by failed weaning attempts, prolonged ICU stay, and even the use of intensive respiratory monitoring and therapy status post extubation if that therapy is outside of the normal 80% statistical bell curve for the patient's given procedure and yes, this includes the simple criteria of increased nursing services and length of stay.

    This is all just CMS compliance, Uniform Hospital Discharge Data Set 101.  Somehow, the auditors forced attempts at requiring an advanced clinical definition and criteria in the name of clinical validation have made everyone forget the basics.  

    You should not need anything beyond some combination of the following: Increased oxygen demands, risk for adverse outcomes from things like Demand MI or Pneumonia,  the inability to wean in a timely manner, an unsafe transfer to the floor due to distress and evidence of high risk of reintubation (atelectasis, congested breath sounds , high work of breathing,  measured hypoxia, altered mental status, high anxiety, inability to follow commands or maintain airway etc.) and standard respiratory failure criteria. 

      Since there is no differentiation between respiratory insufficiency and failure in medical texts, I do not think your search for an accepted magic bullet will prove very productive. 

    One COULD argue that an unexpected and  complete ventilator dependence post-op extending well beyond the expected time interval is post-operative failure while every other form of increased resource utilization beyond the standard post op recovery package for respiratory problems is post op "Respiratory insufficiency".  Since there is no real clinical definition and since coding clink gives us little guidance I suppose that is the best definition you could come up with....at least no one could PROVE you wrong



  • Acute Pulmonary Insufficiency 
    NOT Respiratory!
    NOT Failure.



  • edited April 30
    Acute Pulmonary Insufficiency 
    NOT Respiratory!
    NOT Failure.




    Thank you for the clarification as it does highlight the precise language contained within the codes and by highlighting my incorrect usage of those exact terms, highlights the issues we face where coders must index the exact terms and not interpret their meanings.  

    To be honest (perhaps from my days at the bedside), I just naturally reserve the word "pulmonary" for situations where there is an INTRA-PULMONARY pathology and use "respiratory" for clinical scenarios where there simply a gas exchange issue.  Since nothing I spoke about above implied ARDS or any kind of a direct pulmonary insult, i immediately feel back into using "respiratory" as the operative word.  Many of the specific clinical situations you mentioned above were in fact, pulmonary insufficiency.   In my experience in the real world however,  there is certainly a large subset of patients with impaired gas exchange which don't always have damaged lungs.   I do not have the statistics in front of me but I can buy into your point that a large portion of patients who fail do wean do have intra-pulmonary processes making pulmonary insufficiency a better choice of nomenclature, given that it is expected that neuro, metabolic and other causes of poor gas exchange have been addressed if they are trying to wean the patient in the first place.

    The take away from this is that ICD 10 is as fundamentally broken (I think more so) than ICD 9 was.  

    You have to realize that my friends who are respiratory therapists by nature (and the language in the criteria) specific any failure in gas exchange as a respiratory failure...regardless of the distinction between some malfunction (insufficiency) or a severe malfunction (failure).  Conventional wisdom is that if you have to be intubated and on the vent to survive the respiratory system has failed.    Of course we know that is not how the codes are laid out and I thank you for your explanation above. 

    There is definitely some substance in your explanation above to help stimulate conversation on how one might distinguish pulmonary insufficiency from respiratory failure for both documentation and appeal purposes.  


  • I'd personally advocate that one needs more context and clinical support to query for acute pulmonary insufficiency following surgery other than simply 'requiring 02".   (What is mode of delivery and how much is being delivered - what are the saturations...is the oxygen being provided merely to prevent minor atelectasis?)   I have seen one firm suggest a query for this condition as routine manner  for every patient maintained on MV even on post-operative day one.       "Hooter1964" provided definitions earlier.
  • I'd personally advocate that one needs more context and clinical support to query for acute pulmonary insufficiency following surgery other than simply 'requiring 02".   (What is mode of delivery and how much is being delivered - what are the saturations...is the oxygen being provided merely to prevent minor atelectasis?)   I have seen one firm suggest a query for this condition as routine manner  for every patient maintained on MV even on post-operative day one.       "Hooter1964" provided definitions earlier.

    I have seen that in my days as a coder when I got audited for my job performance.

    I absolutely agree with you that is not appropriate.  Even coding clinic says that when something is a routinely associated finding/standard recovery it is not separately reportable.  The designation of the issue as an unexpected clinical circumstance (and why) is likely even more important than the specific treatment and pathobiology (from a coding stand point).


  • Allen: Precisely 
  • I do not believe there is a consensus as to when it is expected that a patient be weaned from Oxygen supplementation in the postoperative period. Different surgical approaches may induce a large variability
    in this time period. 

    A sequela is an “after-effect” of surgery that is inherent to the procedure (eg, inability to walk after a amputation of the leg).That would be considered "routinely associated finding/standard recovery" 

    All I am trying to do is help out and provide a reasonable interpretation of the statement Acute Pulmonary Insufficiency. I am not the expert. In the first paragraph I stated "When discussing persistence of greater than expected oxygenation problems beyond 48 hours in a post op extubated patient I inquire about whether or not the diagnosis of Acute Pulmonary Insufficiency is applicable with physicians and they simply state they have never heard of the term and or have never seen the definition of it."

    I am heading out to my local Oxygen bar for a bump.....


  • Hi, Hooter.  I appreciate your perspective and your clinical input, as well as that of Allen.   I agree this is a complex issue and there may not be a precise definition.   I just wanted to caution that most often during the typical postoperative period of weaning from the vent that follows something such as MV replacement,  there is no pulmonary deficiency, insufficiency or failure.  I truly have seen some advocate that we ‘need’ to ‘find’ something to query for in such patients, and that is simply wrong unless there  proper context and clinical support.

    Some have even advocated that rather than issue a query for acute postoperative respiratory failure in patients that are on vent for an expected period of time following surgery, that ‘we’ issue a query for acute pulmonary insufficiency in patients that have no clinical signs or symptoms whatsoever of any pulmonary issues, and that are merely maintained on a vent for a short and typical period of time following surgery.   This is entirely unsupported, unethical and needs to be called out for what it is...fraud.

    Paul Evans, RHIA, CCDS
  • I would never advocate this in a patient who has undergone a major thoracic surgical procedure who needs the vent for 3 or 4 days.....The scenario I am talking about is not mechanical ventilation but rather a patient who is Non Thoracic surgery - post op day 4 or 5 who cant get off the nasal o2 without dropping their o2 sats. If pre op they had no underlying respiratory issues and now have become o2 dependent with crappy P/F ratios not requiring mechanical ventilation that is not normal or expected .... 
  • Hooter:  Precisely.  And this is how I took your point the entire discussion.  I just wanted to relate my experience in that 'some' have advocated that 'we' find 'something' of a pulmonary nature to 'code' in patients lacking any clinical support.  This is a real issue IMO because one could report a sole MCC with a POA of "N".  Problematic for so many reasons.  Thank you for the conversation.

  • Hooter:  Precisely.  And this is how I took your point the entire discussion.  I just wanted to relate my experience in that 'some' have advocated that 'we' find 'something' of a pulmonary nature to 'code' in patients lacking any clinical support.  This is a real issue IMO because one could report a sole MCC with a POA of "N".  Problematic for so many reasons.  Thank you for the conversation.


    Exactly...there are some that advocate for it and there are some who's MD's document post op resp failure and insufficiency with no clinical indicators whatsoever. I have a big problem with those dx's  being coded and not vetted.

    Jeff

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