Post procedural respiratory failure

I  have been researching the coding of post procedural respiratory failure; so far the literature I have found supports NOT coding this diagnosis when Post Op Respiratory Failure is documented 0-48 hours after surgery and is on mech vent.  If the respiratory failure continues and meets clinical indicators for respiratory failure related to the procedure  48 hours post procedure, then it should be coded as post procedural resp failure.  Please let me know if your coding dept has an internal policy regarding not coding post op respiratory failure when documented within 48 hours post op...


Suzonne Bourque


  • 48 Hours is an arbitrary number which coding clinic selected but may bear little resemblence to the clinical truth.

    Here is some food for thought;  How soon should a 15 year old who under went general for an ankle fixation procedure after a skateboard accident be extubated?

    That should happen in PACU.  If this patient remains on the vent longer than the immediate post op recovery periods you should have additional diagnoses on the record, one of which could be either acute post op respiratory insufficiency following non thoracic surgery or acute post operative respiratory failure.  I would then try to ascertain a more defined caused of the post op scenario.  "Post - op" meaning after surgery does not necessarily mean "due to surgery" though the coding seems to assume this, it is simply not true.  

    Be that as it may, there is at least SOME reference to the point I am making from coding clinic. 

    1st Q 2017 says:

    "If however the patient remains on mechanical ventilation for an extended period" (the vent hours should be reported). 

    Notice that they have backed away from using an "exact" clock time for this but instead refer to it as an "extended period'.  Now an "extended period" would ordinarily mean several days and would probably be beyond 48 hours before counting vent hours in a great many current cases, but NOT ALL cases.  

    "Extended period" can also include much shorter time frames if the patient was expected to be immediately removed from a vent status post a procedure which does not generally require extended ventilation therapy and in whom no pre-existing pathological state existed which would have possibly rendered a longer post op vent period as an expected finding.  (I wait even LONGER than the suggested 48 hours in an end stage COPD, morbidly obese patient who was a poor surgical candidate to begin with, as I may wait 72 hours before asking the question in such a patient since a protracted vent recovery is an EXPECTED finding)  and in that case you may be OVER reporting at 48 hours....but maybe not. 

    Bear in mind that in the late 90s, we used to keep CABG patients on post op vent for 48 hours as a matter of routine course.  Getting them off around the 24 mark was "new medicine" back then and only done for the patients who were super healthy pre-op.  

    As of 2015, the mean extubation time (and that which CMS is using to calculate it's expected relative weights and length of stays) is 10.21 hours (plus or minus 4).   That means that TECHNICALLY,  you are over the Medpar data averages at the 15 hour mark!!


    The "48 hour" coding clinic is extremely out of date with the clinical truth and current practice standards.  

    However, being assertive on this issue could yield denials from auditing agencies which seek to use the outdated rules to their financial gain.   I would suggest you write to CMS  and complain about the use of this "48 hour standard" as a basis of denials and reviews].  Better yet, have your facility do it as an organized effort rather than dealing with the entry level auditors on a case by case basis until they beat you down with coding clinic arguments and language "gotcha' moments.  (which they are almost guaranteed to do).

    One last consideration which you need to consider in terms of NOT picking it up.  The average global recovery package for a given procedure (and it varies from procedure to procedure as routine CABG recovery looks very different than routine lap appendectomy recovery) INCLUDES the costs associated with recovery in the pricing of the procedure itself.  Meaning that if you do go for the additional MCC of adding a respiratory insufficiency/failure code, only do so if it indeed appears the hospital did in fact expend additional resources for the additional respiratory problems which are OVER AND ABOVE the USUAL and CUSTOMARY post op recovery process for a given procedure.  As I said, given modern advances, the recovery of these post op should be trending down over the last 10 years not up.  Which does give you a little more of an aggressive threshold for "additional resources".

    Hopefully some things for you to consider.  I won't try and answer your question with a simple "yes report it" or "no don't report it' as it is never that simply and I would be highly suspect of any advice you receive which tries to boil it down to a simple black and white answer.  
  • Another way to approach the issue...which we're in the process of doing to ask your Critical Care, Pulmonary, and Anesthesia folks to give your their clinical definition of acute post-op resp failure and codify it as an Institutional definition via the Medical Staff approval process.  This gives you a solid basis for accepting the condition as documented, a basis for clinical validation queries if things don't match the agreed definition, and some additional audit ammunition if you can stand up a definition supported by your physician groups vs their retired psychiatrist reviewer.  (Not foolproof, but you get the idea.)  If you do, I think you'll be surprised how liberal that definition really is.  I know I was.
  • when reviewing a record and trying to differentiate the 'expected' from the complication of a true post operative respiratory failure- I would ask my surgeon how long did they plan on the patient being vented post operatively?  for example for a number of neuro procedures we want to keep the patient sedated and quiet- so if the patient remains on the vent greater than 48 hours but that was the plan this is not respiratory failure. But if the plan was immediate extubation and we are 24 hours still on the vent- the question is WHY?
Sign In or Register to comment.