Documenting the term 'insufficient' is insufficient

 

 

Well, it’s happened again. Because of inappropriate definitions of new disease codes, Medicare could take a massive hit financially and get into yet more problems that they have with other recent loose definitions. Take this very seriously: Do NOT document respiratory insufficiency under ANY circumstances.

 

The Agency for Healthcare Research and Quality (AHRQ) wanted to develop a more secure way to identify postoperative respiratory failure. They have been measuring it as a quality concern in healthcare and the existing code sets have shown to be misused so much so that even AHRQ started tracking the wrong thing. 

 

Even The Delta Group, HealthGrades, Medicare, and others have not been able to correctly identify postoperative respiratory failure. Each group has different ideas of what code sets to use and under what circumstances the surgery caused the respiratory failure or under what circumstances that perhaps surgery had absolutely nothing to do with respiratory failure.

 

Well, the Coordination and Maintenance Committee (CMC) meeting in March 2011 came up with some ideas which it massaged following the comment period. Ultimately, the CMC developed the following definitions and created, very importantly, some exclusions.

 

518.5 Pulmonary insufficiency following trauma and surgery

518.51 Acute respiratory failure following trauma and surgery (New code)

Respiratory failure, not otherwise specified, following trauma and surgery

Excludes: acute respiratory failure in other conditions (518.81)

518.52 Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery (New code)

Adult respiratory distress syndrome

Pulmonary insufficiency following surgery

Pulmonary insufficiency following trauma

Shock lung related to trauma and surgery

Excludes: adult respiratory distress syndrome associated with other conditions (518.82)

aspiration pneumonia (507.0)

hypostatic pneumonia (514)

shock lung, not related to trauma or surgery (518.82)

518.53 Acute and chronic respiratory failure following trauma and surgery (New code)

Excludes: acute and chronic respiratory failure in other conditions (518.84)

518.8 Other diseases of lung

518.81 Acute respiratory failure

Excludes: acute respiratory failure following trauma and surgery (518.51)

518.82 Other pulmonary insufficiency, not elsewhere classified

Excludes: acute interstitial pneumonitis (516.33)

adult respiratory distress syndrome associated with trauma or surgery (518.52)

pulmonary insufficiency following trauma or surgery (518.52)

518.84 Acute and chronic respiratory failure

Excludes: acute and chronic respiratory failure following trauma

 

While this seems very organized it is also very lacking, in my opinion. As there is no uniform definition of respiratory insufficiency in the entire world, the assignment of a specific code for it, both as 518.82 and 518.52, leaves a lot to the imagination of the user. And a lot of opportunity inappropriate coding, inaccurate claims, and potential fraud.

 

Consultants will advise you to take advantage of this new major complication/comorbidity (MCC). But be careful. Not every surgery in the world where the patient either is slowly weaned from a ventilator or just needs some incentive spirometry should be followed with documentation of “postoperative respiratory insufficiency.” That’s pure hogwash.

 

First of all, the combination of trauma and surgery in one code is inappropriate. Patients with trauma, lung contusion, bilateral traumatic pneumothoraces or hemothoraces, patients with crushed tracheas will develop post-traumatic respiratory failure. This should be distinctly different from postoperative respiratory failure and tracked differently. The excuse that researchers can define the clinical circumstance by finding a trauma code is faulty as it can still be the surgery that causes postoperative respiratory failure in the face of an instance of trauma that did not cause the respiratory failure. Use of the present on admission (POA) indicator will not work either as a posttraumatic respiratory failure may not exist on admission.

 

Postoperative respiratory failure, as in the above scenario, should only be reported when problems with the surgical procedure leads to respiratory failure and should not be reported:

If a patient two days after a surgical procedure, develops atrial fibrillation with rapid ventricular response and subsequent acute pulmonary edema and acute respiratory failure and is placed on a ventilator, this will be counted as a complication of the surgical procedure without better definition of the terms of usage. It should be assigned 518.81 even in the postoperative phase rather than 518.51.

 

The terms respiratory insufficiency (postoperative or not) and respiratory distress are being misused. The definitions of the codes by the advisors of how to use them are insufficient; they are being inappropriately assigned nation-wide. Children with mild asthma attacks are being assigned 518.82 everywhere. Patients being purposely weaned from a ventilator slowly because of massive surgery are being documented as having postoperative respiratory insufficiency and being assigned 518.5 everywhere.

 

These definitions are inadequate and they open the door to unethical behavior and fraud.

Since there is no medical definition of the term “respiratory insufficiency,” this concept should be deleted. There are already codes for atelectasis, pneumonia, tension pneumothorax, iatrogenic pneumothorax, aspiration pneumonitis and all of the other permutations of events that can happen in the postoperative phase that is short of acute respiratory failure.

 

By its simple existence, I believe that this code will be overused, and inappropriately so. I predict that billions of dollars of overpayments will be made with the inaccurate assignment of this code and CMS will eventually have to pull it or redefine it. It is a useless concept.

 

The intent of the code was to permit for identification of ARDS that did not progress to acute respiratory failure and is NOT designed to portray a patient who indicated that it “hurts to breathe” due to an upper abdominal or chest incision that actually goes away when the patient receives pain medication and incentive spirometry.