Q&A: Acute respiratory failure with VAT procedures

Q: After a video-assisted thorascopic surgery (VAT) procedure, a patient is usually receiving high flow oxygen. What circumstance might prompt a CDI specialist to query for acute respiratory failure in this situation?

A: As James S. Kennedy, MD, CCS, CDIP, wrote in his article “The complicated process of reporting complications,”

“As we all know, certain conditions routinely occur in the postoperative period. AHA Coding Clinic for ICD-9-CM, Third Quarter, 2009, p. 5, instructs coders to not represent these conditions as complications unless they are more than a routinely expected condition or occurrence, have a cause-and-effect relationship between the care provided and the condition, and are documented as a complication. If uncertain, coders must query the surgeon for clarification. Unless the answer is documented in the medical record, coders may be forced to code conditions as complications. This doesn’t reflect well on the surgeon or hospital.”

Although I am not an expert in the post-operative care of VAT patients, CDI specialists need to determine if there is evidence of clinical indicators to support an acute respiratory failure diagnosis and treatment for the condition that is over and above the normal treatment required for a patient after this procedure. If the patient is slow to wean off the high flow oxygen, or requires further intervention (more than normal for the patient population), and the oxygen saturations, blood gas values, and patient presentation supports the presence of acute respiratory failure, then a query is likely needed.

If this is a common issue for you, speak to your thoracic surgeons and determine what constitutes an expected postoperative course according to the surgical team.

In cases when I was concerned for post-operative respiratory failure for a patient that remained intubated, or receiving high flow oxygen post operatively, my question to the provider always was, “is this different then you expected?” Another way to word it is, “How long did you tell the patient or family to expect to receive this intervention and/or monitoring?” 

This approach allows you to discuss and learn from the surgical team concerning an expected patient course. And, it also allows you to offer education to the providers concerning the documentation needed to identify a post-operative complication and to ensure one is not reported when it is inappropriate to do so.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI education specialist at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.