Respiratory failure....

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Good morning everyone.

I am second guessing myself on a record and would love some feedback.

I am reviewing the chart of an expired patient. The patient came in with a nonsurvivable brain stem hemorrhage and was only hospitalized for approx 10hrs. We currently have NO CC or MCC on the record. The MD specifically states there is no mass effect or midline shift. No mention of cerebral edema or brain compression. The patient was maintained on the ventilator however the ED note states that he was “intubated for airway protection”. No mention of resp distress, ABG is normal, and he does have spontaneous respirations. Based on this, I was opting not to query on resp failure as I do not see indicators. Then I noticed the ED note does list “respiratory arrest” on the problem list.

Am I right in NOT querying on this record or am I not be aggressive enough?

Thanks in advance!

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

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Be aggressive Katy. If the patient was intubated, even for airway protection, they should indicate a diagnosis to go along with the treatment in order to justify it. Just my thoughts, but we had a patient code here recently and no one documented cardiac or respiratory arrest until I sent out the query as to why CPR and intubation was initiated. Needless to say it ended up being an enlightening discussion with the provider involved.

    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
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • digardskdigardsk
    edited May 2016
    How about coma?

    Kim
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes. Coma is documented and coded.

    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
  • jlindseyjlindsey
    edited May 2016
    Brain death? 34882 - MCC - 4/4.

    Jill Lindsey, RN, BSN, CCDS

    Phoenix Children's Hospital
    Clinical Documentation Specialist
    Ext. 3-0725
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Nope. They specifically say he is not brain dead....

    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
  • cnolan@swgeneral.comcnolan@swgeneral.com
    edited May 2016
    Encephalopathy?
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Good idea. Our MD's are generally resistant to documenting encephalopathy in our comatose patients. But it's a good idea.

    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
  • cnolan@swgeneral.comcnolan@swgeneral.com
    edited May 2016
    Exactly, but they certainly wax and wean!
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Robert,

    Thanks for your input. I have heard a lot about how "resp failure" is not supported by documentation such as need for airway protection. Basically my only CI of resp failure is the treatment. But if they are attributing the vent to "airway protection" can I use that as a CI of resp failure?

    This will likely be the only MCC on the record (if I did query and get a + response) so I want to make sure it is defensible.

    Thanks!

    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
  • robert.hodges2robert.hodges2
    edited May 2016
    I would query and the reason is they were doing it for a reason. It's not like a surgical case where they keep patients intubated and it's planned. This sounds more acute and they either saw something or suspected something. In my opinion it's always worth asking the question, and who knows you may even get the answer.

    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

    VA Core Values:  Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
    VA Core Characteristics:  Trustworthy, Accessible, Quality, Innovative, Agile, Integrated

    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
  • robert.hodges2robert.hodges2
    edited May 2016
    Oh yea, and I'd use my "Treatment without diagnostic indication" query. :)

    Robert
     
    VA Core Values:  Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
    VA Core Characteristics:  Trustworthy, Accessible, Quality, Innovative, Agile, Integrated

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
  • ssalinasssalinas
    edited May 2016
    Respiratory arrest is a MCC. Can you use that since it is on problem list?

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Resp arrest will not be a CC on this patient since he died on this admission.

    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
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