Q&A: Acute pulmonary insufficiency

Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (PSI) if it’s failure. 

A: Our process is to review the chart and see if it meets clinical evidence for additional specificity such as acute respiratory failure. If it does not, does it meet clinical evidence for acute respiratory distress (now that there is a new code for that condition)? If it does not, then our CDI teams would not query. If it does meet the criteria, we would add all the relevant information from the record on the query and ask the physician if, in his or her medical opinion, the documented acute pulmonary insufficiency could be further specified.

It also must meet the criteria for being a reportable condition. We used to have to address this on coronary artery bypass graft patients. Some of the physicians were documenting post-operative respiratory failure when the patient was expected to be on the ventilator for a few hours. In reality, the ventilator was an integral part of the procedure and was expected.

Since the Tabular Index now takes the coder directly to the chapter in ICD-10 and post-op in coding terminology means “due to,” we believe this to be the very definition of ambiguity because we understand that our physicians use the phrase “post-op” to indicate a timestamp.

Therefore, our CDI specialists are working hard to stamp out the phrase “post-op” and instead encourage the physicians to document the diagnosis and the underlying known or suspected cause. I have also written to AHA Coding Clinic to ask them to recommend that the term “post-op” without an etiology be queried.

For example, acute respiratory failure due to underlying severe bullous COPD or acute respiratory failure due to ventilator acquired pneumonia.

If the physician documents only “post-op” with the condition without the etiology, we query.

Editor’s note: This question was answered by Charrington Morell, RN, CCDS, director of CDI at HCA West Florida Division Office in Tampa. The answer was given based on limited information. If you have a CDI question, send it to ACDIS Editor Linnea Archibald (larchibald@acdis.org.)