Respiratory failure denials
We have recently encountered a couple of denials with acute respiratory failure as a secondary diagnosis. The auditor stated that a blood gas must be done in order to assign the code despite all of the clinical indicators we provided that support the diagnosis. Has anyone else experienced this issue? Our physicians do not do blood gases on every patient because they see it as not being helpful and painful for the patient.
Comments
Jackie Touch
Typically the audit contractors disregard the authoritative diagnostic standards cited on appeal with attached medical literature sources with no explanation why they believe these do not support acute respiratory failure, and arbitrarily reject any appeals simply citing their previous decision and repeating the explanation. In most cases you have to get thru the audit contractor's appeals and go directly to the payer's validation team or an independent adjudicator for anything close to a fair hearing.
Hospitals should complain directly to their payer representative for redress of the auditors' nefarious, arbitrary, unsubstantiated, unresponsive and clinically incorrect methods. Also ask if you can bypass the contract auditor and go directly to the payer's appeal unit where there is a history of repeated abuse by auditors for certain frequent diagnoses like acute respiratory failure, saving everyone time and money!
The diagnostic standard for acute hypoxemic respiratory failure (except for patients on continuous home O2) is:
- PO2 <60mmHg or consistent SpO2 <91% on room air
- PO2/FIO2 ratio <300 while breathing supplemental oxygen
For patients on continuous home O2, flow rate is adjusted to keep PO2 >60mmHg / SpO2 >91%. For these patients PO2 <60mmHg / SpO2 <91% while receiving their usual home O2 flow rate or more confirms an acute decompensation of chronic hypoxemic respiratory failure. The PO2/FIO2 ratio will always be <300 in these patients so may not be convincing.The PO2/FIO2 ratio is a particularly valuable indicator for patients (not on continuous home O2) already started on oxygen at the hospital, but auditors are usually clueless and oblivious to it.
For the widely-accepted authoritative diagnostic standards of acute respiratory failure and the other most commonly encountered diagnoses pertinent to CDI programs you can refer to the CDI Pocket Guide available from ACDIS which also provides thorough discussions and authoritative clinical references.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
Dr. Pinson. I find your input extremely candid and helpful! I do use the PO2/FIO2 ratio when considering this clinical topic and I find it very helpful given so many patients arrive to an ED whilst undergoing aggressive therapy by the EMS and or an ABG is taken hours after the patient has been treated.
Paul Evans, RHiA
If it's the surgeon's intent to keep the patient intubated overnight or so then there's not a diagnosis to correspond to this. I have seen "failure to extubate" written by Anesthesia and have had to query to ensure there was not an issue post-op that required the patient to remain intubated. I do not know a lot about Physician billing but have always been told that it's the intensivist "needing" a diagnosis for the ventilator management but have also been told that they can simply bill for ventilator management.
I think we as CDI need to query when there are no indicators of respiratory failure to ensure that the most accurate picture is portrayed. If this is a trend at your facility, this would be an excellent topic for Provider educator and/or escalation to a Physician Advisor (we do not have one).
Jeff
Excellent articles, physician comments and sample queries are available on this website by searching 'resources'. The dependency code would not be valid for a patient that is on a vent for an expected period of time following various procedures.
Query:
On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has ***.
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 expected.Paul Evans, RHIA
Obvious Edit issues with document I am attempting to show:
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Query:
On DATE documentation in the NOTE TYPE section of the medical record indicates the patient has ***.
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:*1The 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 2Respiratory 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 3Respiratory failure is present and is related to patient’s other conditions / co-morbidities, or other non-surgical cause – please specify* 4Unable to determine5Other
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 expected.Sorry - I can't really paste my communication in a clear manner.
Paul E.
1. 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
If #1 is true, there is no dx or code to be applied. Also, see below reference from Faye Brown regarding reporting mechanical ventilation (I always find myself going back to it and the coding clinics regarding mechanical ventilation).
"When mechanical ventilation is utilized during surgery, it is not normally coded when it is considered a normal part of surgery. However, in the event that the physician documents that the patient has a specific problem and is maintained on the mechanical ventilator longer than expected or if the patient requires mechanical ventilation for an extended period of time postoperatively, it may be coded. If the postoperative mechanical ventilation continues for more than two days, or if the physician has clearly documented an unexpected extended period of mechanical ventilation, the mechanical ventilation may be reported separately. The hours of mechanical ventilation should be counted starting from the point of intubation.
Jeff
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
From my perspective, Jeff is right on. I would also full agree with Dr. Pinsons comments.
From my perspectives, respiratory management that is either A) A part of the global surgical and recovery package or
A known circumstance and expectation based on the patients pre-existing diagnose and co-morbidities then the condition should not be reported.
That is how I teach beginners, but also why I avoid talking to you experts. *wink*.
The only thing I saw that caught my attention was Dr. Pinsons comment that he avoids the P/F ration for chronic respiratory failure patients. I don't avoid entirely, I just adjust it down to an expected 250 to 275 range and if it goes below that, I start looking at that piece of data again.
Will be interesting to see if he chimes in to tell me I an crazy.
Is there a reference available that cites the expected 250-275 range and is there an equivalence for SF ratio?
Always looking for more resources to add to the arsenal.
Thanks!
Jackie Touch
If a patient presents with shortness of breath, labored breahing, tachypnea at resp rate of 30, but oxygen saturation is 95% on room air. The oxygen saturation doesn't meet criteria for respiratory failure, but the other symptoms do.
Thank you for your response. We often see patients come through ER and apparently are in distress but do not meet criteria for respiratory failure. They might improve for a bit, only to decompensate a day or two later into respiratory failure and subsequent intubation. These are patients that have COPD exacerbation, acute CHF,etc. Thanks again
There is a coding clinic that address that you do not need ABG's: Second Quarter 1990 page 20 to 21
True: ABG values are not required, but does the cited sat of 95% support acute respiratory failure versus something such as hyperventilation? I'd personally not advocate for ARF with this sat rate.
Paul Evans, RHIA, CCDS
I had read Dr Pinson's articles on acuter respiratory failure (ARF) and was under the impression that a patient had to require at least 40% oxygen or 5 liters nc to meet criteria for ARF. After reading the section in our new CDI handbook, it appears that this concentration of oxygen isn't required to meet criteria, but just as intubation and bipap almost always means the patient is in ARF, 40% or 5 liters does as well. Is this correct?