Respiratory Failure after Open Heart Surgery

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

  • 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.

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

  • 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.
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