Q&A: Acute pulmonary insufficiency denials

Q: Have any other institutions had frequent clinical validation denials regarding acute pulmonary insufficiency following surgery? If so, what clinical indicators and resources do you use to appeal the denials?

A: Acute pulmonary insufficiency following thoracic/non-thoracic surgery is an MCC, so it’s frequently a denial target. Without an organization-wide definition for the diagnosis, you will be at risk of denials. It’s also considered a complication with some service lines as reported by the Emergency Care Research Institute (ECRI).

When you’re digging into the charts that were denied, pay close attention to the criteria the pulmonologists use when documenting the condition. In some cases, they may be documenting the condition any time they were consulting post-operatively for ventilator management, but the patients were extubated and placed on oxygen without complications.

In these situations, provide education to the pulmonary critical care providers on this topic and explain that some DRGs (e.g., CABG, etc.) include the ventilator management and labeling it as acute pulmonary insufficiency is incorrect.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.