Acute Pulmonary Insufficiency Following Surgery (thoracic and non-thoracic)
Have any other institutions had frequent clinical validation denials regarding Acute Pulmonary insufficiency following surgery?
If so, what are your clinical indicators & resources utilized to appeal in support of the assignment od Acute Pulmonary Insufficiency following Surgery?
Have there been cases overturned?
Comments
As acute pulmonary insufficiency following thoracic/non-thoracic surgery is an MCC, it is frequently denied. We have taken the approach that without a standard definition of this diagnosis, it does put us at risk. It is also considered a complication with some service lines as reported by ECRI.
We started deep diving these denials and discovered that the pulmonologists were documenting this when they were consulted post operatively for vent management. These patients were extubated and placed on oxygen without complications. We then educated the pulmonary critical care providers on this topic and explained that the DRG (CABG, etc) already had this piece built in and labeling it as acute pulmonary insufficiency was not correct.
My advice is to deep dive those denials and see what you find!
There is no ‘like’ button, but if there were, I would push it for the response provided by jcjohnson. My biggest issue, too, is that there is no definition.
Clinical example:
65 yr old male with COPD & chronic respiratory failure (chronically on 2L/m at all times at home) is s/p sigmoid resection for colon cancer and has had difficulty coming off of mechanical ventilation for 72 hours, but is able to come off at 84 hours (3.5 days).
a. would this be considered Post-Operative Respiratory Failure?
b. would it be compliant to query for Acute pulmonary insufficiency following non-thoracic surgery... if the patient has a chronic issue (COPD, OSA) that is contributing to the difficulty in coming off of mechanical ventilation, is J95.2 the right code... is this already expected and no additional codes are necessary?
c. do facilities have specific guidelines as to what is PORF, i.e. on Mechanical ventilation after surgery for greater than 48 hours, 72 hours, 96 hours?
d. is there any utility to query for Acute pulmonary insufficiency following thoracic or non-thoracic surgery if it is a high-risk for denial?
Thanks for your input in advance,
Rob
Greetings Rob, Great question and hoping you find my answer helpful. The first point I want to make is that anything titled post op is considered to be directly caused by the surgery.
The average cost of routine/expected post-op mechanical ventilation or respiratory care is included in the Surgical DRG payment. Post-op respiratory failure/pulmonary insufficiency indicates an increased resource utilization above the routine/expected post op care.
Questions to ask: Is the need for mechanical ventilation post-op expected for the kind of surgery? Is the duration of mechanical ventilation expected for the kind of surgery? Are there any pre-existing conditions like CHF or COPD contributing to respiratory failure? If so, have providers clearly document that link. We have encouraged providers to document that as well as respiratory failure due to other medical conditions. This will be an exclusion from a PSI if documented as such.
If patient is unable to wean, requires reintubation, respiratory distress, etc., it may very well be failure.
Kind Regards,
Jeanne