Vent for Airway Protection

Unknown

Hi - Looking for feedback on how others handle this scenerio - patient vented with documentation clearly stating they were vented for airway protection with no resp compromise. For example, a patient requiring sedation while going through DT's.

Some on my team believe this is sufficient documentation and do not query for acute resp failure. The rationale being the MD indicated the reason for venting the patient. Others on the team believe the MD should be queried for acute resp failure, acute pulmonary insufficiency, etc. The rationale being airway protection isn't codeable.

Any insight/feedback would be appreciated. Thanks.

david.smith

I wouldn't code acute respiratory failure unless it was documented as such. I think reporting a specific dx like acute respiratory failure based only on a treatment option is inferring a bit too much.

robert.hodges2

I agree. It doesn't look like failure to me either.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

dbutler

Generally, we do not pursue an additional dx (acute resp failure, etc.) when the documentation clearly shows airway protection and there are no clinical indicators for significant resp compromise.

The common example I've seen is for sz and post-tictal states with intubation (especially for a short period of time). Don't believe there is an opportunity there, and don't wish to force one either.

Your example is I believe comparable for a patient undergoing general anesthesia for surgery and is weaned from the vent within the customary time frame for the procedure (which may be in the OR suite, or may be as much as 24 hours or so later in an ICU as with CABG/Valve).

The clinical situation is what it is......

Don

david.smith

Here is a link to a CDItalk Q&A with Dr. Gold that addresses this topic
very well. In short, it defaults to the doctor to make the call as to
whether the airway protection was due to acute respiratory failure, to
prevent ARF or other reasons (aspiration risk?)

http://www.cditalk.com/showthread.php/176-Airway-protection-vs-Respirato
ry-failure