Acute post op pulmonary insufficiency following surgery denials
Good morning,
Are any of you getting denials regarding the documentation of acute post op pulmonary insufficiency following surgery? The diagnosis is being denied because the surgeon didn't establish a cause-and-effect relationship (complication) between the pulmonary insufficiency and the surgery. Per 3M, the word "following" establishes the cause and effect so there's no need to query unless there is clinical evidence supporting another cause. However, our coding department is pushing for us to query for cause and effect every time this is documented due to the denials.
I'm very interested in everybody's viewpoint on this.
Comments
What is the precise wording of the documentation that is being denied?
Sounds like the 3rd party is not contesting the clinical validity?
Thank you for responding. I’ll get the precise verbiage posted Monday. I appreciate your weighing in.
Here's the verbiage from the denial:
"Revise J95.1 acute pulmonary insufficiency following thoracic surgery, to J98.4 other disorders of lung. Acute postop pulmonary insufficiency has been noted in the record. When checking the Tabular for J95.1, it is noted category J95 is labeled 'Intraoperative and postprocedural complications and disorders of respiratory system NEC.' In this case acute pulmonary insufficiency following thoracic surgery was not documented and the acute pulmonary insufficiency has not been documented to be a complication of the surgery. See ICD 10 OCG Section I.B.16 on Documentation of Complications of Care which states, 'Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication.' Per indexing, Acute postoperative pulmonary insufficiency indexes under; Insufficiency - pulmonary (without begin specified as a following thoracic surgery complication) to arrive a code J98.4."
The documentation by the provider states, "Acute post op pulmonary insufficiency." The patient is status post thoracic surgery. In this case, there is no other possible underlying etiology for this condition.
Thanks for taking the time to offer your viewpoint.
The 3rd party wants this to be stated very explicitly, based on what you cited. (Cause & Effect)
My only cautionary note would be to ensure there is no other potential cause of respiratory insufficiency, such as a COPD exacerbation, CHF, non-cardiac cause of pulmonary edema or TACO? (Transfusion associated CV overload)
I know I am bending pedantic, but such is the nature of coding and some of the auditors are pretty stringent?
I have a form you may like? I think your coding is defensible if there is no other potential cause for this issue? But, my opinion carries no bearing with the 3rd party
Others may have other insight. I can share my form with you, if you like. But, I am pretty sure it is in the library now.
evanspx@sutterhealth.org
Thank you. I'll check the library for the form. Appreciate your insight.
You can mail me directly, if you wish
evanspx@sutterhealth.org