Q&A: Establish clinical criteria prior to querying for COPD

Q: We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure in this instance) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia. They tell us Chronic Obstructive Pulmonary Disease (COPD) is chronic respiratory failure by definition. Can you help us clarify this situation or give us some tips on how to educate our physicians?

A: I see two pieces of education as needed in this situation. First, we need to establish the diagnostic criteria for chronic respiratory failure. Many physicians do consider COPD as chronic respiratory failure. But not every patient with COPD requires continuous oxygen support. Some require oxygen at night only, others only as needed, and others do not require oxygen at all.

If your organization has not developed an agreed-upon definition of both acute and chronic respiratory failure now is the time to do so. Work with your pulmonologist to define these terms with examples of the clinical indicators needed to make the diagnosis. These clinical indicators would then be the standards the CDI specialists and coders would use to determine if a query is needed as well. Once you have an agreed upon criteria, you can use it as part of your physician education.

Examples of diagnostic criteria for chronic respiratory might include:

• Persistent decrease in respiratory function
• Chronic continuous home oxygen
• Chronic hypercarbia due to respiratory condition (i.e. pCo2>40)
• Use of chronic steroids for underlying lung pathology
• Polycythemia

Secondly, physicians need to understand that wording such as “end stage lung disease,” “severe lung disease,” or use of the GOLD staging for COPD, does not lead to a code assignment that reflects chronic respiratory failure. Using the clinical indicators such as those above, discuss with the physicians that not every person with COPD meets such criteria. Some are more severe than others, and as mentioned above not all require oxygen. Not all require chronic steroid use.

A patient with chronic respiratory failure has a higher severity of illness (SOI) and risk of mortality (ROM). These patients have a much lower threshold to enter acute respiratory failure. They can decompensate very quickly. The physicians may not understand why the wording of chronic respiratory failure is so important.

We need to ensure the physicians understand how important it is to capture the SOI/ROM that accurately reflects their patients’ conditions. This will affect both the quality measures assigned to the organization and to the physicians.

I hope this information helps.Please let me know if you need further assistance and also if you discover a “magic cure” to this documentation issue.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.