Q&A: Documenting ARDS when not present on admission

Q: Recently, we’ve seen a few situations in which respiratory failure was present on admission (POA), but then later in the stay, the patient’s condition progresses to acute respiratory distress syndrome (ARDS) or the physician determines that it is ARDS. In these situations, our coding team is capturing ARDS as not present on admission. The patient, however, has had similar presentation the entire stay. Do you recommend querying for POA? In circumstances when it was determined to be ARDS upon further study, should it be coded with a POA of yes? 

A: I recommend sending a query to clarify the POA status after a close CDI review is performed. I also recommend the CDI specialists investigate the case for clues of ARDS to see if the clinical indicators can be tracked back to the time of admission, therefore supporting POA status. This would eliminate the need for a query unless the CDI program policy is to query regardless.

During the CDI review for ARDS, ask questions such as:

• How fast was the onset?
• Did the patient come in for respiratory failure? What are the symptoms?
• What does the chest x-ray look like? (Ground glass opacities, or bilateral infiltrates are often associated with ARDS).
• What type of oxygenation are they getting?
• Are they ventilated? 
• What medications are they on?
• Is the patient being places in the prone position?
• Are they getting positive end expiratory pressure (PEEP)? 
• Are the providers talking about extracorporeal membrane oxygenation (ECMO)?

Also, remember that acute respiratory failure is a component of ARDS, so you wouldn’t code both. However, a patient cannot develop ARDS without also having acute respiratory failure. Codes J9601 and J80 coded together will generate an Excludes1 note.

Regarding the pathophysiology, increased capillary permeability is the hallmark of ARDS. What typically happens here is that neutrophils are sent to the lungs by cytokines, become activated and release toxic mediators. Inflammation due to neutrophil activation is key to the pathophysiology of ARDS. The membrane surrounding the lung becomes weak, while proteins leak causing more havoc.

The problem is trying to prevent the bursting of the alveoli, which is why the CDI specialist could see PEEP being employed on ventilated patients. PEEP will keep the alveoli open for ease of gas exchange and helps to prevent the bursting of the alveolar. If ARDS is not documented and you see ECMO discussed or documented in this scenario, suspect ARDS. From a high-level overview, ECMO essentially does the gas exchange for the damage alveoli.

The onset of ARDS tends to be quick as the lungs begin to fill will fluid. Part of the provider’s workup is to differentiate between pneumonia and an acute episode of heart failure because the symptoms and appearances on the chest x-ray are all very similar. As in congestive heart failure, pulmonary hypertension and pulmonary edema can be present with ARDS. Acuity and the etiology should always be documented for pulmonary edema in a patient with ARDS.

Treatment can involve ventilation, PEEP, treatment of the underlying condition, fluid management (often restrictions), prone positioning, and ECMO. Steroids are normally a part of the treatment for most ARDS patients. Note that with COVID-19 patients who have developed ARDS, however, steroids may not be implemented.

Diagnostics should include imaging of the chest either by chest x-ray or CT, frequent blood gasses, and physical exams. To date, there is no diagnostic test to confirm ARDS.

POA status can be tricky when it comes to ARDS because of its sudden onset. CDI specialists should always question it when the patient begins with acute respiratory failure and ends up with ARDS, which includes tracking the clues backwards for that “after study” piece. Talk to the providers (when it’s appropriate in light of the current COVID-19 situation) and see how they diagnose ARDS. Understanding how your providers view this diagnosis is key in guiding the query process.

Mortality for ARDS is high and tends to increase with age. Therefore, accurate capture of all conditions for these patients is crucial for mortality scoring.

According to an article in The Lancet, providers are seeing ground glass opacities in COVID-19 patients that they believe to be from the virus. One report showed a case with mild symptoms of shortness of breath and fever that had bilateral ground glass opacities on the chest x-ray. This can make the diagnosis of ARDS even more difficult to distinguish from other conditions. What the CDI specialists can do to help providers is to have a good understanding of ARDS to allow for presenting relevant clinical indicators through the query process so the provider can determine if ARDS exists.

Editor’s note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist with HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. To listen to the ACDIS Podcast episode discussing COVID-19, click here. For information regarding CDI Boot Camps, click here.