Radio Recap: Defining acute respiratory failure in provider documentation

What’s the biggest issue related to for reporting respiratory failure diagnoses? It all starts with the definition, said Robert Stein, MD, FCCP, CCDS, associate director of the MS-DRG assurance program for Enjoin, during the July 13, 2016 ACDIS Radio broadcast.

At his former practice, Stein said each of the six pulmonologists had a different definition of acute respiratory failure. Provider documentation of this condition in the medical record is often unclear, not only due to inconsistent definitions, but also as a result of loosely-used terminology, such as “respiratory distress” versus “respiratory failure.”

“At the end of the day, a lack of a consistent definition that all providers can follow is the biggest issue.”

Identifying clinical indicators that support acute respiratory failure could result in improved documentation, said Stein.

Acute respiratory failure represents a potentially life-threatening condition that requires hospitalization. During the program, Stein offered his insight as a pulmonologist by providing possible definitions and clinical indicators for acute hypoxic or hypercapnic respiratory failure:

• Hypoxemic respiratory failure means that the patient does not have enough oxygen in their blood, while their levels of carbon dioxide are close to normal. Clinical indicators include a PaO2 of less than 60 mmHg or arterial oxygen saturation that is less than 90%.
• Hypercapnic respiratory failure means there’s too much carbon dioxide in the blood, and normal or not enough oxygen. Clinical indicators in this case include an elevated Pco2 of 50 millimeters of mercury (though Stein says some use 45 millimeters) and a reduction in pH of less than 7.35.

Stein looks for signs of increased work of breathing, which supports the premise that the patient is in acute distress. Documentation could include an elevated respiratory rate of roughly 26-28 breaths per minute or “difficulty speaking in full sentences,” said Stein.

The next piece is intervention, which, for an acute respiratory failure patient, could include O2 supplementation or bypass intervention. Finally, increased resource use indicates the level of the life threatening condition, Stein said. If the patient is admitted with a life-threating disorder, they will require at least a monitor bed, if not an intensive care unit bed.

“The doctors will tend to agree on the definitions,” says Stein. “It’s the other points, the indicators, where there’s some divergence and an opportunity for CDI to [collaborate with coders, physicians, and other staff to determine facility-wide guidelines].”

Editor’s note: ACDIS Radio is a bi-weekly talk show covering the hottest topics in CDI. Tune in every other Wednesday at 11:30 a.m. ET. To listen to past shows, click here.