Q&A: Acute pulmonary insufficiency following surgery

Q: Recently, we’ve seen an uptick in clinical validation denials regarding acute pulmonary insufficiency and acute respiratory failure following surgery. What can we do to fight or prevent denials for these diagnoses?

A: As acute pulmonary insufficiency following thoracic/non-thoracic surgery is an MCC, many organizations have issues with it being denied.

Without a standard organization wide definition for this diagnosis, facilities may find themselves at risk for denials and in some service lines, acute pulmonary insufficiency is considered a complication. After taking a deep dive into these denials, some find that pulmonologists document this diagnosis when they were consulted postoperatively for ventilator management. Such  patients, however, may be  extubated and placed on oxygen without complications. When such documentation trends are identified, some physician education may be warranted.

Let’s look at a clinical example:

A 65-year-old male with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure (chronically on 2L/m at all times at home). Patient is status post sigmoid restriction for colon cancer and has difficulty coming off of mechanical ventilation for 72 hours but is able to come off at 84 hours.

Would this be considered post-operative respiratory failure? Would it be compliant to query for acute pulmonary insufficiency following non-thoracic surgery?

First, keep in mind that anything documented as “postoperative” is considered to be directly caused by the surgery. However, physicians understand “postoperative” to mean an action took place in a specific time frame after the operation. ICD-10-CM interprets it as a condition that occurred due to the surgery. Postoperative respiratory failure, a condition caused by/due to the operation would add to the clinical resources required and could trigger quality of care measures for the organization. The average cost of routine/expected postoperative mechanical ventilation or respiratory care is included in the surgical DRG payment.

When reviewing the medical record, CDI specialists need to ask:

• Is the need for mechanical ventilation postoperative expected for the kind of surgery performed?
• Is the duration of mechanical ventilation expected for the kind of surgery?
• Are there any preexisting conditions like congestive heart failure (CHF) or COPD contributing to respiratory failure?

If there are preexisting conditions, make sure the providers clearly document that link in the patient record, which may be an exclusion from a patient safety indicator.

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.