Radio Recap: Acute respiratory failure FAQs

Under documentation. That’s the biggest concern when it comes to acute respiratory failure diagnoses, according to 42% of respondents to a poll during the February 8 episode of ACDIS Radio. A slight majority, however, (49% of respondents) stated over-diagnosis/clinical validation as their number one issue.

“If you’ve already conquered under-documentation, then over-diagnosis/clinical validation seems like it’s the only problem left,” Richard Pinson, MD, FACP, CCS, principal of Pinson & Tang in Houston, Texas, said on the program.

When it comes to documenting and coding acute respiratory failure, many facilities run into the problem of “post-op pulmonary insufficiency” in the physician documentation. “Often, physicians think it’s something minor, but coders assign it as ‘respiratory failure,’ which is a very serious term,” Pinson said.

This diagnosis commonly crops up in the intensive care unit, Pinson said. The intensivists want some sort of diagnosis for post-operative ventilation so it can be coded, but a “post-op pulmonary insufficiency” diagnosis opens up the facility to clinical validity audits because care for such patients typically does not rise to the critical level ascribed to “respiratory failure.”

For surgeons, a post-operative acute respiratory failure diagnosis ends up as “big black mark on their quality ratings,” Pinson said. Rather than inciting anger in the surgeons right off the bat, “talk to the intensivists first before getting the surgeons all lathered up because the intensivists are doing something incorrectly,” Pinson suggested.

Ultimately, when it comes to acute respiratory failure, Pinson suggested an educational approach with your physicians rather than an approach through queries. If you query them, they may continue documenting the same way in the future. Education will have a more lasting impact. “Somebody’s gotta teach them,” Pinson said.

Editor’s Note: To listen to the complete ACDIS Radio show from February 8, “Acute Respiratory Failure FAQs,” click here. On the program, Pinson also addressed hypoxia, hypoxic respiratory failure, and their criteria. To read a Q&A on the same subject, click here. For an in-depth dive into coding and documentation concerns as well as a look at how such measures affect quality reporting, join us on March 21, 2017, 1:30-2 p.m. EST, for a live webinar.