ACDIS insight: Identifying acute pulmonary insufficiency following surgery
by Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC
Here at ACDIS, we’re frequently asked about specific criteria for the diagnosis of acute pulmonary insufficiency following surgery. Although it is similar to postprocedural respiratory failure, acute pulmonary insufficiency following surgery will not trigger a Patient Safety Indicator (PSI), so it is often seen as a desirable alternative diagnosis to capture.
To help to mitigate clinical validation denials, many organizations have developed organizationally defined criteria for the diagnosis of acute respiratory failure, making the task of evaluating its presence more straightforward. Most organizations, however, have not established similar guidelines or criteria for the diagnosis of acute pulmonary insufficiency following surgery, making it more challenging to identify.
Acute pulmonary insufficiency generally occurs in patients with preexisting conditions such as chronic obstructive pulmonary disease (COPD), current or history of smoking, interstitial lung disease, hypoventilation due to obesity and/or chronic heart failure.
Additional contributing factors that may increase one’s risk of developing acute pulmonary insufficiency following surgery include reduced lung expansion due to pain or abdominal distention or the use of sedatives or narcotics inhibiting deep breathing. At times, conditions such as atelectasis, aspiration pneumonia, pulmonary edema or pulmonary embolus may also develop. After surgery, these conditions further impair the patient’s respiratory status and increase the risk of adverse health outcomes.
With acute pulmonary insufficiency, there is usually a greater-than-expected problem either oxygenating or ventilating beyond what is expected, requiring intensive observation and treatment. These patients typically exhibit prolonged oxygenation requirements or have an increased need for oxygen, potentially escalating to high flow oxygen therapy.
Occasionally, patients may require non-invasive ventilation like BiPAP or CPAP to eliminate excessive carbon dioxide. The diagnosis is often perceived as less severe than respiratory failure, but still significant enough to qualify for a reportable diagnosis. This necessitates an increase in monitoring, evaluation, assessment, treatment, or extending the hospital stay or nursing resources needed to safely care for the patient.
It’s important to remember that a while a diagnosis of acute pulmonary insufficiency following surgery will add an MCC to the record, signifying the increase in severity of illness, risk of mortality and consumption of resources, it will not serve as an exclusion for PSI 11, Postoperative Respiratory Failure. Since most PSI 11 cases are triggered when mechanical ventilation persists beyond 96 consecutive hours or reintubation occurs, adding the diagnosis of acute pulmonary insufficiency following surgery will have no impact on the PSI status. It may however replace a documented or potential diagnosis of acute postoperative respiratory failure which, on occasion, may be responsible for triggering PSI 11.
For best practice, we recommend organizations identify and discuss common clinical indicators for the diagnosis of acute pulmonary insufficiency following surgery with their CDI and coding departments. They should ensure providers understand when it is appropriate to document the diagnosis and how to differentiate between acute pulmonary insufficiency and acute respiratory failure. Establishing organizationally defined criteria in collaboration with clinical and compliance departments can help to support documentation integrity efforts, reduce denials and the inappropriate triggering of PSIs.
References:
- AHRQ (2025) Patient Safety Indicator 11 (PSI 11) Postoperative Respiratory Failure. AHRQ Quality Indicators (AHRQ QI) ICD-10-CM/PCS Specification v2025. https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2025/TechSpecs/PSI_11_Postoperative_Respiratory_Failure_Rate.pdf
- Manz, J & Prescott, L (2025). 2026 ACDIS Pocket Guide: The Essential CDI Resource. HCPro LLC.
Editor’s note: Rice is a CDI education specialist at ACDIS/HCPro. Contact her at Kelly.rice@hcpro.com.