Note from the Instructor: Reporting post-operative acute respiratory insufficiency versus failure

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Recently, I came across a discussion on the ACDIS Forum about physicians’ failure to document acute respiratory insufficiency or, in many cases, over-documenting the conditions post-operatively.

From a coding/reporting standpoint, respiratory insufficiency or failure (depending on the severity and the provider’s judgement) should not be reported during the normal post-operative recovery period as the definition (found in the Official Guidelines for Coding and Reporting’s discussion of reportable diagnoses) applies to coding and hospital resource use and is not just clinical criteria. Surgical MS-DRGs already account for the increase use of resources related to post-operative recovery.

Some providers try to document every patient as having postoperative respiratory insufficiency as they attempt to capture their work of managing the ventilator. Reporting requirements for the inpatient hospital stay are very different than those for capturing physician resource use, and evaluation and management code assignment, however.

CDI professionals should also ask what the significant clinical difference is between a patient on a ventilator for 47.5 hours and a patient on a ventilator for 48 hours. It’s a trick question.  There isn’t any difference. A 48-hour period is arbitrary from a clinical standpoint, though it may be relevant as an average cost standard. 

Be that as it may, AHA Coding Clinic, First Quarter 2017, deviates from the 48-hour standard and simply says that ventilator hours are separately reportable when a patient is on the ventilator longer than expected for a given procedure. Note the verbiage is “extended period”, which for some patients may be several days, but for others could be a shorter time frame (reference below).

A teenager who received care for an open tibial fracture repair is likely to be on a vent for a much shorter period than an 80-year-old morbidly obese patient with end-stage chronic obstructive pulmonary disease (COPD) who underwent a heroic AAA rupture repair. So, the number of hours as a measure is highly variable from one patient to another.

In coding, if the extensive resource use related to respiratory failure is not clear from the reported ICD-10 procedure code then additional code assignments become necessary to fully tell the patient’s story and a post-operative respiratory diagnosis could be warranted if those additional resources were expended.

Such documentation may identify failed weaning attempts, a prolonged intensive care unit (ICU) stay, and even the use of intensive respiratory monitoring and therapy status post-extubation, if that therapy is outside of the normal 80% statistical bell curve for the patient’s given procedure. And yes, this also includes the simple criteria of increased nursing services and length of stay.

This is all just CMS compliance, Uniform Hospital Discharge Data Set 101. Somehow, auditors’ attempts at requiring an advanced clinical definition and criteria in the name of clinical validation seem to have made everyone forget the basics.

Coders and CDI professionals should not need additional documentation beyond some combination of the following:

• Increased oxygen demands
• Risk for adverse outcomes from things like demand myocardial infarction or pneumonia
• The inability to wean in a timely manner
• An unsafe transfer to the floor due to distress and evidence of high risk of reintubation (atelectasis, congested breath sounds, high work of breathing, measured hypoxia, altered mental status, high anxiety, inability to follow commands or maintain airway, etc.)
• Standard respiratory failure criteria

Since there is no differentiation between respiratory insufficiency and failure in medical texts, searching for a universally accepted magic definition will not prove very productive.

One could argue that an unexpected and complete ventilator dependence post-operatively extending well beyond the expected time interval is post-operative failure while every other form of increased resource use beyond the standard post-operative recovery package for respiratory problems is post-operative respiratory insufficiency. Since there is no real clinical definition and since Coding Clinic gives us little guidance, I suppose that is the best definition I can come up with—at least no one could prove me wrong! Be that as it may, don’t be surprised if you get a denial when a patient is clearly kept on the ventilator or in the unit for the provider’s and staff’s convenience, due to a lack of an available bed for transfer, etc. If there were no attempts to even wean a patient from therapy in conjunction with a lack of documentation explaining the nature and need for extended post-operative respiratory services, you’re at risk for a denial.

Editor’s note: Frady is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.