Respiratory Failure after Open Heart Surgery

jillian.bisbejillian.bisbe
in Clinical & Coding

I have a question regarding routine mechanical ventilation after open heart surgery. What do you recommend your providers document?  Example- Pt to ICU after open heart, weaned per normal protocol, extubated within 4 hours.

Our Md’s write Acute Post Op Resp Failure but as you know that causes a PSI.  What do you recommend they write to prevent a query but also cover for their critical care time?

Comments

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    Expected ventilator management

    Years ago MD's were taught that they needed a dx to bill for their critical care time and that's where this practice started. This should be highly discouraged for the reasons you mentioned.

    I think there are many discussions on the forum that are archived.

  • jillian.bisbejillian.bisbe

    I'm wondering- should they even be billing for critical care time since they don't truly have respiratory failure?

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
    jillian.bisbe said:

    I'm wondering- should they even be billing for critical care time since they don't truly have respiratory failure?

    I'm not an E/M expert but I would think that it would be appropriate since they are managing a critically ill patient.
  • drew.siegel205drew.siegel205
       PSI 11 (Postop resp failure) excludes DRGs falling into MDC 5 (diseases/disorders of circulatory system) category. Cardiothoracic procedures will be excluded from this PSI.
       When acute resp failure is documented in the postop setting and there are no supporting clinical indicators and the patient is promptly extubated (within 24-48 hrs), then I would query for confirmation. 
       
       
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