Q&A: Handling respiratory failure denials

Q: We’ve been getting denials on acute respiratory failure from Medicare Advantage plans. We are appealing them, but we still have not had them overturned. CDI specialists do also review these patients’ records for the respiratory failure criteria. For example, this is what the Medicare Advantage plans are sending us:

Acute respiratory failure with hypoxia is not validated and has been removed as a diagnosis code assignment consistent with documentation received, for the following reasons:

• Arterial blood gas (ABG) not obtained
• Need for low dose supplemental oxygen is clinical manifestation expected with pneumonia
• No need for assistive ventilation devices such as bi-level positive airway pressure support or mechanical ventilation
• Oxygen supplementation via nasal cannula is often provided in the home setting and is not considered, in of itself, a treatment for acute respiratory failure

From my review of the records, these patients met the respiratory failure criteria. In every one of these cases, respiratory failure is the only MCC other than the principal diagnosis on the account (all of these denials had respiratory failure as the secondary diagnosis). I’m thinking this is what is kicking the account out for their review.

Here are my findings:

• PF ratios are all below the less than 300 most all below 250.
• Room air, 0s saturation in most of the case 90% or below.
• Some had signs of distress, others didn’t but had low saturation below 90%

How would you suggest we fight these denials?

A: I may not be able to solve this one for you with a simple answer. Denials are a tricky thing. I did put together some things to consider to help you formulate a plan of action, though.

First of all, an ABG is not necessary for the diagnosis of acute respiratory failure, supplemental oxygen is the primary treatment for respiratory failure, and assistive ventilatory devices such as BiPAP or mechanical ventilation are not required to establish the diagnosis.

According to the 2018 CDI Pocket Guide:

“For a patient to have acute respiratory failure, it must be symptomatic and meet diagnostic criteria based on arterial blood gas (ABG), P/F ratio, or pulse oximetry readings (SpO2).” In addition, the “diagnostic criteria for hypoxemic respiratory failure are pO2 < 60 (SpO2 < 91%) on room air, or a P/F ratio < 300 on oxygen.”

Based on your own findings, it appears that your record review supports the diagnosis of respiratory failure, although if no signs of distress (e.g., respiratory rate greater than 20, shortness of breath, tripod breathing, speaking in short sentences, signs of cyanosis such as loss of color in the nailbeds and lips, confusion, use of accessory muscles, etc.) the diagnosis may not be supported.

Here are some other questions to consider for an appeal response:

1. What was the patient’s baseline respiratory function?
2. Did they have chronic respiratory failure on home oxygen?
3. What, if any, was the patient’s baseline morbidity in regard to their respiratory function?
4. How much from baseline has the oxygen requirements increased and or oxygen saturation decreased?
5. Was the patient in any visible sign of distress in the emergency department or on admission on physical assessment?
6. Did you attempt to ascertain the Medicare Advantage’s policy in regards to their requirements for approving respiratory failure?

Your appeal response should address each of the bullet points included in the denial rationale, and emphasize the acute respiratory failure diagnostic criteria with supporting clinical references.

Editor’s note: Allen Frady, RN-BSN, CCDS, CCS, CRC, a CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question, with the help of Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, principals of Pinson and Tang, based in Houston, Texas. Pinson and Tang are also the authors of the CDI Pocket Guide and the Outpatient CDI Pocket Guide: Focusing on HCCs. Contact Frady at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement- boot-camp-1.