WOndering how many do not require ABG's to document Acute Respiratory Failure in Adults? Do you just uyse clinical picture (tachpnea, O2 Sats, etc or must you have ABG's appreciate your responses.
The definition used in our query form for Acute states: Develops over minutes to hours, Change in 2 or more ABG values and/or other physical symptoms. pH of ≤ 7.30; if history of COPD, pH ≤ 7.50 pCO2 of ≥50 on room air pO2 of < 60 on room air RR of ≥ 24 Alteration in mental status: anxiety Accessory muscle use Unable to speak in complete sentences Ventilator support required
The key word here is the "or" so we don't rely on ABG values exclusively.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
I don't always use ABG's either. It's great if they are done, but that doesn't always happen. I look for the clinical picture - tachypnea, accessory muscle use, retractions, inability to speak in complete sentences, sats, color, etc.
Many times we do not have ABG's done or they were not obtained on room air.
Our query does include ABG indicators (pO2, pCO2, pH, O2 SATs, RR, etc.) but I look for other clinical signs to verify the diagnosis and pose it within the query.
Hello, It is my understanding that you can have respiratory failure without intubation and mech vent. Therefore, if the pt was intubated to protect the airway then you lose the mech vent. The physician must tie the respiratory failure to the continued need for the mech vent. If this is done then you have an mcc but not a pdx unless the physician also indicates the resp failure was poa. Clear as mud? Hope this helps. Gail Eaton RN PCCN CDS Clinical Documentation Specialist
Since the indicator are present and a Dx of resp failure - I suggest you query the physician for clarification. Hope that helps.
Susan Fantin, RN, BSN, MSA, CCDS, CDIP Senior Director, Clinical Documentation Improvement Specialist, Performance Technologies The Advisory Board Company 202-266-5862 direct | 248-321-0256 mobile | 202-266-5700 fax fantins@advisory.com | www.advisory.com Stay in the know
Thanks. This does help some. The physician and I discussed this and he said it was like an induced resp failure. He actually documented pt was not on vent for pulmonary problems.
Coding Clinic, Third Quarter 2012 Page:21 Effective with discharges: September 15, 2012
Question:
A patient presents to the Emergency Department (ED) due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the intensive care unit (ICU) and documents that the patient was intubated for airway protection because of the drug overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the following next day. Can the coder assume that the patient was in respiratory failure and report code 518.81, Acute respiratory failure, based on the fact that the patient was intubated and placed on mechanical ventilation for airway protection?
Answer:
Do not assign code 518.81, Acute respiratory failure, simply because the patient was intubated and received ventilatory assistance. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated (e.g., respiratory failure) needs to be clearly documented by the provider.
I did see this coding clinic. I think the thing that puzzles me is that he was adamant about documenting acute resp failure because he had to manage the vent yet admitted the pt was not really in acute resp failure clinically. I wasn't sure if this was what he needed for his billing
I would ask him to clarify in his documentation the clinical indicators he saw for respiratory failure. We are seeing denials from RAC for diagnosis that the physician documents but there are no clinical indicators in the record. At best Acute Respiratory Failure is going to be your MCC for your Seizure DRG 100(unless physician stated seizure was secondary to ?) and no DRG impact from the vent. Dorie
Thank you all so much for your input. I feel better thinking I was going in the right direction. This just makes reading the chart very confusing. I wanted to make sure my discussions w/ the physician were not incorrect and thus get him totally frustrated w/ me
I also see the documentation of ARF for ‘protection of airway’. Unless indicators are met, it won’t fly; I agree with the advice offered by Dorie. Some of our physicians have been told they ‘must’ document Acute Respiratory Failure in order to bill E/M for ventilator management. This is not accurate, but many seem to have this belief. I find that often the Medical Staff will confuse medical necessity with E/M coding with acute inpatient coding and the conflicting rules inherent in some of these systems.
Some of our staff are under the impression they ‘must’ use a ‘different’ diagnosis and corresponding code than the surgeon. Example: Pt undergoes CABG for CAD. Surgeon codes/reports CAD or CM or CHF for their E/M.
Subsequently, the ICM staff ‘feel’ they can’t use this code – this is what I have been told in my conversations with them. Therefore, they will use ‘acute respiratory failure’ for ‘their’ E/M codes to support management of the patient. IMO, this is not correct. There is no rule or regulation within the Medicare part B manuals that state each physician must report a separate principal diagnosis code from any another physician if billing services on the same date of service (DOS). This is good news for physicians who may be under the impression that each separate E/M encounter needs a separate diagnosis. This being said if the treating physician is indeed managing the patient for a separate, medically necessary reason then this reason should be reported by the appropriate diagnosis code. However, it is not required that the physician document a separate reason if it’s not warranted. It is also good to mention that RAC (and many other payer audit groups) look for consistent documentation. For instance, RAC will deny a claim if the patient’s clinical picture or indicators were inconsistent with the diagnosis reported. This simply to shows that physician documentation must always support the patient’s clinical picture, in other words the medical necessity. To summarize, a patient managed in the ICU s/p CABG should reflect the appropriate cardio-diagnoses, regardless of the treating specialist.
Postoperative Respiratory Failure Many physicians document “acute respiratory failure” in the postoperative period, even though it is usual and customary for the procedure. This may occur when patients are maintained on a ventilator following surgery even though it is a routine and expected aspect of the patients care inherent to the procedure performed. In other words, the respiratory failure is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis.
It ‘may’ be appropriate to code if:
Ø Physician documents it as not routinely expected or as a complication of the procedure Ø Physician documents as due to another cause or due to medications or anesthesia Ø Mechanical Ventilation is required for more than 48 hours after surgery or reintubation with mechanical ventilation is performed
Effective October 1, 2011, codes 518.51, Acute respiratory failure following trauma and surgery; 518.52, Other pulmonary insufficiency, not elsewhere classified; and 518.53, Acute and chronic respiratory failure following trauma and surgery, have been created to distinguish postoperative acute respiratory failure from less severe respiratory conditions such as shock lung, drowned lung, pulmonary and lung insufficiency following shock, surgery or trauma, wet lung syndrome, adult respiratory distress syndrome (following shock, surgery, or trauma) and acute idiopathic lung congestion; conditions that only require supplemental oxygen or intensified observation.
Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation. Risk factors may be specific to the patient's general health, location of the incision in relation to the diaphragm, or the type of anesthesia used for surgery. Trauma to the chest can lead to inadequate gas exchange causing problems with levels of oxygen and carbon dioxide. Respiratory failure results when oxygen levels in the bloodstream become too low (hypoxemia), and/or carbon dioxide is too high (hypercapnia), causing damage to tissues and organs, or when there is poor movement of air in and out of the lungs. In all cases, respiratory failure is treated with oxygen and treatment of the underlying cause of the failure. Source: AHA Coding Clinic• for ICD-9-CM, 4Q 2011, Volume 28, Number 4, Pages 123-125
How unfair is that? Facilities can not get credit for caring for someone who is placed on a vent for airway protection when you know without it they will aspirate and develop Pneumonia etc. So much for getting adequate compensation for resource utilization! I guess if your hospital is struggling financially you might as well place the drug OD patient in rescue position and pray.
Katy, The new CDI Pocket Guide 2014 has some great definitions to use. It discusses the P/F ratios as well as other criteria.
Autumn Reiter, R.N., B.S.N., CCDS Clinical Documentation Improvement Coordinator Health Information Services Chesapeake Regional Medical Center 736 Battlefield Boulevard North Chesapeake, VA 23320 Phone: 757-312-3142 Autumn.reiter@chesapeakeregional.com
Katy, The links below are to an article Dr. Pinson wrote on respiratory failure. I use this a lot in my RAC appeals to justify acute respiratory failure (with great success). I use the P/F ratio for all types of patients. His article written for ACP Hospitalist is a two part series and is packed full of great information. Hope this helps.
Katy, I also tell my staff to consider the Jet Neb treatments. Many times we have patients admitted with "respiratory distress" however they have been on continuous jet nebs from the ED to the unit. Also, can the patient converse in full sentences.
Good Luck Lisa
Lisa Romanello, RN,BSN,FNS,CCDS Manager, Clinical Documentation Improvement Quality and Compliance CJW Medical Center 804-228-6527
Katy, The links below are to an article Dr. Pinson wrote on respiratory failure. I use this a lot in my RAC appeals to justify acute respiratory failure (with great success). I use the P/F ratio for all types of patients. His article written for ACP Hospitalist is a two part series and is packed full of great information. Hope this helps.
You're welcome! ACP Hospitalist is a great website and I search it regularly for clinical support to reference on my audits. Worth saving as a favorite
Comments
Develops over minutes to hours, Change in 2 or more ABG values and/or other physical symptoms.
pH of ≤ 7.30; if history of COPD, pH ≤ 7.50
pCO2 of ≥50 on room air
pO2 of < 60 on room air
RR of ≥ 24
Alteration in mental status: anxiety
Accessory muscle use
Unable to speak in complete sentences
Ventilator support required
The key word here is the "or" so we don't rely on ABG values exclusively.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
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
Our query does include ABG indicators (pO2, pCO2, pH, O2 SATs, RR, etc.) but I look for other clinical signs to verify the diagnosis and pose it within the query.
NBrunson, RHIA, CCDS
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
It is my understanding that you can have respiratory failure without intubation and mech vent. Therefore, if the pt was intubated to protect the airway then you lose the mech vent. The physician must tie the respiratory failure to the continued need for the mech vent. If this is done then you have an mcc but not a pdx unless the physician also indicates the resp failure was poa. Clear as mud? Hope this helps.
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
Susan Fantin, RN, BSN, MSA, CCDS, CDIP
Senior Director, Clinical Documentation Improvement Specialist, Performance Technologies
The Advisory Board Company
202-266-5862 direct | 248-321-0256 mobile | 202-266-5700 fax
fantins@advisory.com | www.advisory.com
Stay in the know
Michelle Jones, RN, BSN
Clinical Documentation Specialist
Vidant Roanoke Chowan Hospital
252-209-3012
msjones@vidanthealth.com
Mechanical ventilation for airway protection
Coding Clinic, Third Quarter 2012 Page:21 Effective with
discharges: September 15, 2012
Question:
A patient presents to the Emergency Department (ED) due to an overdose
of Ambien and is intubated and placed on mechanical ventilation. The
attending physician admits the patient to the intensive care unit (ICU)
and documents that the patient was intubated for airway protection
because of the drug overdose. There was no documentation of respiratory
failure and the patient was weaned from the ventilator the following
next day. Can the coder assume that the patient was in respiratory
failure and report code 518.81, Acute respiratory failure, based on the
fact that the patient was intubated and placed on mechanical ventilation
for airway protection?
Answer:
Do not assign code 518.81, Acute respiratory failure, simply because the
patient was intubated and received ventilatory assistance. Documentation
of intubation and mechanical ventilation is not enough to support
assignment of a code for respiratory failure. The condition being
treated (e.g., respiratory failure) needs to be clearly documented by
the provider.
that he was adamant about documenting acute resp failure because he had
to manage the vent yet admitted the pt was not really in acute resp
failure clinically. I wasn't sure if this was what he needed for his
billing
Michelle Jones, RN, BSN
Clinical Documentation Specialist
Vidant Roanoke Chowan Hospital
252-209-3012
msjones@vidanthealth.com
Dorie
in the right direction. This just makes reading the chart very
confusing. I wanted to make sure my discussions w/ the physician were
not incorrect and thus get him totally frustrated w/ me
Michelle Jones, RN, BSN
Clinical Documentation Specialist
Vidant Roanoke Chowan Hospital
252-209-3012
msjones@vidanthealth.com
Some of our physicians have been told they ‘must’ document Acute Respiratory Failure in order to bill E/M for ventilator management. This is not accurate, but many seem to have this belief. I find that often the Medical Staff will confuse medical necessity with E/M coding with acute inpatient coding and the conflicting rules inherent in some of these systems.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Subsequently, the ICM staff ‘feel’ they can’t use this code – this is what I have been told in my conversations with them. Therefore, they will use ‘acute respiratory failure’ for ‘their’ E/M codes to support management of the patient. IMO, this is not correct.
There is no rule or regulation within the Medicare part B manuals that state each physician must report a separate principal diagnosis code from any another physician if billing services on the same date of service (DOS). This is good news for physicians who may be under the impression that each separate E/M encounter needs a separate diagnosis. This being said if the treating physician is indeed managing the patient for a separate, medically necessary reason then this reason should be reported by the appropriate diagnosis code. However, it is not required that the physician document a separate reason if it’s not warranted. It is also good to mention that RAC (and many other payer audit groups) look for consistent documentation. For instance, RAC will deny a claim if the patient’s clinical picture or indicators were inconsistent with the diagnosis reported. This simply to shows that physician documentation must always support the patient’s clinical picture, in other words the medical necessity.
To summarize, a patient managed in the ICU s/p CABG should reflect the appropriate cardio-diagnoses, regardless of the treating specialist.
Postoperative Respiratory Failure
Many physicians document “acute respiratory failure” in the postoperative period, even though it is usual and customary for the procedure. This may occur when patients are maintained on a ventilator following surgery even though it is a routine and expected aspect of the patients care inherent to the procedure performed. In other words, the respiratory failure is due to the procedure, falls within the routinely expected time frame, and does not require unusual resources, thus should not be considered a complication nor coded as an additional diagnosis.
It ‘may’ be appropriate to code if:
Ø Physician documents it as not routinely expected or as a complication of the procedure
Ø Physician documents as due to another cause or due to medications or anesthesia
Ø Mechanical Ventilation is required for more than 48 hours after surgery or reintubation with mechanical ventilation is performed
Effective October 1, 2011, codes 518.51, Acute respiratory failure following trauma and surgery; 518.52, Other pulmonary insufficiency, not elsewhere classified; and 518.53, Acute and chronic respiratory failure following trauma and surgery, have been created to distinguish postoperative acute respiratory failure from less severe respiratory conditions such as shock lung, drowned lung, pulmonary and lung insufficiency following shock, surgery or trauma, wet lung syndrome, adult respiratory distress syndrome (following shock, surgery, or trauma) and acute idiopathic lung congestion; conditions that only require supplemental oxygen or intensified observation.
Respiratory failure is a relatively common postoperative complication that often requires mechanical ventilation for more than 48 hours after surgery or reintubation with mechanical ventilation after postoperative extubation. Risk factors may be specific to the patient's general health, location of the incision in relation to the diaphragm, or the type of anesthesia used for surgery. Trauma to the chest can lead to inadequate gas exchange causing problems with levels of oxygen and carbon dioxide. Respiratory failure results when oxygen levels in the bloodstream become too low (hypoxemia), and/or carbon dioxide is too high (hypercapnia), causing damage to tissues and organs, or when there is poor movement of air in and out of the lungs. In all cases, respiratory failure is treated with oxygen and treatment of the underlying cause of the failure. Source: AHA Coding Clinic• for ICD-9-CM, 4Q 2011, Volume 28, Number 4, Pages 123-125
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
So much for getting adequate compensation for resource utilization! I guess if your hospital is struggling financially you might as well place the drug OD patient in rescue position and pray.
For some reason Katy I believe there is a coding clinic w/ARF Clinical Indicators.
You can always email Pinson/Tang - he may send you the references he has or even an article.
Thanks,
Norma T. Brunson, RHIA,CDIP,CCS,CCDS
The new CDI Pocket Guide 2014 has some great definitions to use. It discusses the P/F ratios as well as other criteria.
Autumn Reiter, R.N., B.S.N., CCDS
Clinical Documentation Improvement Coordinator
Health Information Services
Chesapeake Regional Medical Center
736 Battlefield Boulevard North
Chesapeake, VA 23320
Phone: 757-312-3142
Autumn.reiter@chesapeakeregional.com
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
The links below are to an article Dr. Pinson wrote on respiratory failure. I use this a lot in my RAC appeals to justify acute respiratory failure (with great success). I use the P/F ratio for all types of patients. His article written for ACP Hospitalist is a two part series and is packed full of great information. Hope this helps.
http://www.acphospitalist.org/archives/2013/10/coding.htm
http://www.acphospitalist.org/archives/2013/11/coding.htm
LeeAnn Cheung-Conaway RN III, CCRN, CCDS
UPMC Altoona, Quality Management Dept.
Clinical Documentation Specialist - Coordinator
Office 814-889-3313
Cell 814-502-6772
Fax 814-889-3766
I also tell my staff to consider the Jet Neb treatments. Many times we have patients admitted with "respiratory distress" however they have been on continuous jet nebs from the ED to the unit. Also, can the patient converse in full sentences.
Good Luck
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
804-228-6527
Claudine Hutchinson RN (CDI)
918-502-6603
Katy,
The links below are to an article Dr. Pinson wrote on respiratory failure. I use this a lot in my RAC appeals to justify acute respiratory failure (with great success). I use the P/F ratio for all types of patients. His article written for ACP Hospitalist is a two part series and is packed full of great information. Hope this helps.
http://www.acphospitalist.org/archives/2013/10/coding.htm
http://www.acphospitalist.org/archives/2013/11/coding.htm
LeeAnn Cheung-Conaway RN III, CCRN, CCDS UPMC Altoona, Quality Management Dept.
Clinical Documentation Specialist - Coordinator Office 814-889-3313 Cell 814-502-6772 Fax 814-889-3766
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
Leah Taylor, RN, CCDS, CCA
Data Integrity Specialist/CDI & RAC Coordinator
Iredell Health System
557 Brookdale Drive
Statesville, NC 28687
704-878-7436 office
704-878-4624 fax
leah.taylor@iredellmemorial.org
This might help on Resp Failure
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville NC
DButler@vidanthealth.com
Also, in the Jan 2014 ACDIS Journal, pg 21, Dr. Pinson provides an excellent overview of the topic, and this article has some citations.
Paul Evans, RHIA, CCS, CCS-P, CCDS