Q&A: Respiratory failure denials

Q: I am hoping to get some feedback on a new type of payer denial. Respiratory failure was clinically supported in the home environment via the emergency services (EMS) run sheet clinical indicators. The ambulance crew initiated treatment, so the patient was not tripoding nor hypoxic any longer when they hit the emergency room. The patient then remained on high-flow O2. The provider documented acute respiratory failure in the history and physical (H&P) along with chronic obstructive pulmonary disease (COPD) exacerbation. Patient was admitted for respiratory failure and COPD exacerbation.

The payer is now denying respiratory failure based on lack of clinical support. The reasoning is that the “EMS run sheet is not owned by the hospital and the patient did not have physical exam findings to support respiratory failure by the time that they hit the emergency department [ED].”

Do you use clinical indicators from EMS run sheets to clinically validate the diagnoses documented by a provider in the ED and/or H&P? Or would you have not captured the respiratory failure? This is the first denial we’ve received saying the EMS run sheet is not owned by the hospital. In other words, they do not want to allow the use of clinical indicators from the EMS runs sheet. Have others received these denials? How are you handling them?

Response #1: The question I would ask is whether the EMS run sheet is considered part of the patient’s legal medical record for the episode of care. If so, the clinical indicators and diagnoses can be used. I’d also argue that this aligns with new advice from the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice—2022 Update, which says “Clinical Indicators may be sourced from the entirety of the patient’s health record including but not limited to: Emergency services documentation (e.g., emergency service transport, ED provider, ED nursing).”

Response #2: Personally, I would not have suggested a query based off of an EMS run sheet. To the contrary, when a provider documents a diagnosis only supported by evidence that occurred prior to arrival to our hospital, we would have suggested a clinical validation query with the first option being: “Respiratory failure resolved prior to arrival” and would not have captured it in our code set.

Response #3: We do use the EMS run sheet. If we see no physical symptoms in the ED or in the H&P, we query for the provider to get what occurred and was witnessed by EMS into their documentation.  

For example, if the provider documents “acute hypoxic respiratory failure,” we’ll ask for validation by including “per EMS, patient tripoding, breathing labored, hypoxic at 86% on room air,” etc. By bringing the EMS documentation into the actual hospital record, we have had success in appropriately capturing the acute hypoxic respiratory failure diagnosis.

Response #4: I understand your predicament. It could be questionable as they appeared stable once arriving to your facility; however, regardless of the EMS run sheet being owned by another entity, it does paint the picture of what happened outside of your facility. You didn’t mention how much O2 the patient was on when they arrived. That has been a big part of our issue. If the O2 amount was only 2-4L, that can be hard to support unless you have documented desaturations. I always try and calculate the P/F ratio for those patients who do not wear home O2 to support my case.

Another piece we have done is encourage providers to turn the oxygen down or off while they are present and assessing the patient. We all know patients look really good in bed on oxygen, but we ask them to turn it down and make the patient sit up or get out of bed. If the patient shows signs of decompensation during that time, the provider can easily document that to paint the true picture. I know payers are very egregious and that can make our job difficult, but these are some tips that have worked for us.

Response #5: I would use the EMS run sheets and heavily reference Coding Clinics that provide reference to occurrence outside the facility. There are several Coding Clinics that are specific to transfers from Hospital A and Hospital B. The COVID Coding Clinics and guidance has a lot of information specific to “confirmation.” Specifically, Coding Clinic, first quarter 2021, and Coding Clinic, second quarter 2017, may be particularly helpful to you. The Coding Clinics do not have to be specific to the respiratory failure per se. The Coding Clinics provide detail for accurate code assignment. I would also cite the CMS program integrity manual and definitions for clinical validation. Also, is the EMS service using your facility protocols? If so, I would include that in the appeal.