Q&A: Acute pulmonary insufficiency criteria

Q: Do you query for acute pulmonary insufficiency? If so, what criteria do you use?

Response #1: We have recently begun to educate our providers (especially cardiothoracic surgeons) on using this diagnosis. We tell them to utilize it for those patients that require supplemental oxygen but do not meet criteria for respiratory failure (unable to wean, higher oxygen concentration than expected). We also highlight the difference in the terms of respiratory and pulmonary. Respiratory is related to breathing or respiration, while pulmonary is related to or pertaining to the lungs. Acute postoperative pulmonary insufficiency may be used to represent those patients that fail to follow the normal weaning pattern from mechanical vent to room air following surgery.

I spoke with our denials team, and they have not received any denials with this code from our system or other systems that they deal with. Of course, we know that eventually that will likely change as the code gets used more.

Response #2: This is the criteria we use:

• Acute pulmonary insufficiency is the diagnosis applying to a post operative patient that does not meet criteria for acute respiratory failure but has hypoxia requiring minimal oxygen.
• Frequent causes:
  
  • Atelectasis
  • Fluid overload
  • Morbid obesity
  • Anesthesia/analgesics effects
• Requiring up to several liters of oxygen (may be intermittent) for several days post op and even with discharge.
• Hypoxia frequently resolves with pulmonary toilet, ambulation, or chest physical therapy of oxygen for hypoxia post-operatively.

Response #3: We do have success with this. Below is an example of a query we have sent:

Remain as an inpatient due to post-op O2 use of 3-6L was documented in 10/25 note.

Please review the following and provide your response in the progress notes and discharge summary. Which Dx reflects the patient's condition most accurately?

• Acute pulmonary insufficiency following non thoracic surgery
• Acute postoperative pulmonary insufficiency
• Other, please specify
• Clinically unable to determine

Clinical Indicators: 

• Preoperative VS: 97.5, 74, 18, 125/73, 97% RA
• 10/24: TRANSFORAMINAL LUMBAR INTERBODY FUSION, L4-5, L5-S1, Vertebroplasty
• 10/25 PN: Pt will need to remain as an inpatient due to post-op O2 use of 3-6L of O2 with decreased resp of 7 and 2.
• 10/25 NN: 2 L desats at room air
• 10/26 NN O2 1 L NC
• 10/26 PN:  POD 2 O2 saturation rate had dropped to around 80% after removal of her NC and while transitioning to the bedside chair. Her O2 was re administered by the nurse via NC at 2L and returned to 92%. Likely will need O2 at discharge
• 10/27: 92%  2L NC. 86% RA>O2 @ 2L NC resumed. Treatment: Monitor, O2 supplementation-wean, continue Incentive spirometer - 10x/hr while awake. 

Another department reviews denials at our organization, but we work closely with them and have not had any issues identified.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.