Post-op Respiratory Failure

ginpin

I am confused about Post-op Respiratory Failure. Does the post-op Respiratory Failure default to Post Traumatic Pulmonary Insuff (518.5) for an MCC??
I was of the understanding that in order to get the MCC, the physician must document Acute post-op pulmonary insuff for the MCC. Any information would be greatly appreciated.
Thank you
Regina McCroskey, BSN
Munroe Regional
Ocala, Fl

Unknown

May I suggest focusing on the clinicals of the case as opposed to trying to catch that MCC. The coders will determine whether the condition is a MCC or not. See the link below for a decent reference on respiratory failure.

Good luck.

http://www.thoracic.org/clinical/critical-care/clinical-education/respiratory-failure-mechanical-ventilation.pdf

ginpin

Thank you for responding to my question. However, clarification is need to determine whether a query is in order. Assigned to the ICU and Intermediate Care Units, these diagnoses come across my path frequently. I have seen in some instances where Post-op Respiratory Failure coded to "Pulmonary insuff due to Surgery/trauma" with out a post-discharge query. My questions are: (1) Is "Post-op Respiratory Failure equal to Acute Respiratory Failure, or does it default to Pulmonary Insuff due to surgery/trauma? Is a query needed here? (2) Does Pulmonary insuff have to say "Acute" Pulmonary Insuff post-op; and (3)are "Respiratory Insuff and Pulmonary Insuff" the same in the coding world? As you can tell I am not a coder and I ask these questions to keep from asking physicians unnecessay (silly) questions.
Determining/clarifying whether a diagnosis is a MCC/CC is very important for the CDI program at my facility. We get most of the diagnoses clarified before the record reaches the coders to decrease the amount of post-discharge queries generated.
As you can see any information on how to handle these diagnoses is appreciated. If anyone has a cheat sheet, please pass it on!!!
Thank you
Regina McCroskey,RN. BSN
Munroe Regional Medical Center
Ocala, Fla

catladyrn

I would consider documentation of postoperative respiratory failure as 518.5, but if I saw it coded as 518.81, that would be ok to me, too. If you run respiratory failure through an encoder, unless you state it is chronic, it defaults to acute. If you state it is due to surgery, trauma, or shock, it goes to 518.5. Either way it is an MCC. I would not query if it is documented the way you state; it is good enough.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

david.smith

I ran some scenarios thru the trusty encoder:
(Acute) Respiratory Failure following/due to surgery = 518.5
(Acute) Pulmonary Insufficiency following/due to surgery = 518.5
ACUTE Respiratory Insufficiency following/due to surgery = 518.5
Respiratory Insufficiency, not specified as ACUTE = 786.09
Respiratory Failure (acute)(unspecified) = 518.81 (however there is a selection choice "due to surgery/trauma/shock" which takes you to 518.5 if you
Are selecting "Acute" but you don't get that path if you go with "unspecified" respiratory failure)

So basically, if you have documentation of respiratory failure or pulmonary insufficiency you should get the MCC captured, the only problem scenario would be documentation of "respiratory insufficiency" only (i.e. not acute). Then you would probably want to query for acuity.

jolene.file

Interesting to see it will be addressed in the next Coding Clinic release -1st Qrtr.2011
Thanks for sharing.

Jolene File, RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder

Unknown

It is also tabled for discussion at the next C & M committee meeting in Baltimore. Obviously, there is some thought this code is being "overused."

catladyrn

What I find overused is the term "VDRF." The patient might be on a vent from major surgery the previous day (expected outcome) and even though they're weaning on schedule and will probably be extubated later that day, if the physician sees the ventilator, they write "VDRF" and the coder takes it to 518.5. I had been able to convince my docs at my previous hospital that they should try to meet criteria (about 48 hours on the vent by all the journal articles I researched, only sooner with clinical evidence of distress) before writing VDRF, but now I'm a way smaller fish in a way bigger pond.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

david.smith

Unless the documentation was that of "acute postop respiratory insufficiency" the coder should have taken it to 786.09. The term "acute" is required to get to 518.5 if documented as "respiratory insufficiency". Interestingly, the definition of the code itself is "pulmonary insufficiency.." not failure. If you are presented with "pulmonary insufficiency due to surgery" then you go directly to 518.5, failure doesn't need to be documented at least from a coding perspective. I definitely agree that this is an area needing some official guidance or coding terminology revision. It seems like a difficult area to query as far as "insufficiency" vs "failure" 

ssalinas

At the current time, Pulmonary Insufficiency following surgery is coded 518.5 The statement of acute is not needed since ‘acute’ in this case is a nonessential modifier. (When a word appears in parenthesis next to an entry, it is nonessential or not needed to use the code.)



However Respiratory Insufficiency following surgery is coded to 786.09. It must be described as acute by the physician to get to 518.5 since the term ‘acute’ is not a nonessential modifier for respiratory insufficiency. Strange but true.



( ) Parentheses are used in both the index and

tabular to enclose supplementary words which

may be present or absent in the statement of

a disease or procedure without affecting the

code number to which it is assigned. The terms

within the parentheses are referred to as

nonessential modifiers.



Insufficiency


Sharon 

kelly.skorepa@uhhospitals.org

If the dx is documented, aren't you obligated to either code it or query
for documentation of supporting clinical evidence?

Kelly Skorepa RN BSN
kelly.skorepa@uhhospitals.org