UASI Monthly CDI Scenario Discussion – October 2019

Topic: Clinical Validation:

Acute Post Operative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure

Scenario:

  • H/P: 65 y/o male with past medical history of DMII, HLD, HTN, and obesity admitted with chest pain worse on exertion.
  • Medications: Insulin, Metoprolol, Lisinopril, ASA, Crestor. BMI 34.
  • Patient had a positive stress test.
  • Cardiac cath shows severe three vessel disease and patient underwent 3 Vessel CABG for his CAD.
  • Patient had uneventful procedure (and was transferred to ICU on ventilator).
  • Weaning from ventilator was started five hours postoperatively with patient extubated ten hours postop and placed on 2L N/C.
  • Progress note on hospital day two (first postop day), “Patient is back to his baseline not requiring supplemental oxygen. Acute postop pulmonary insufficiency resolved.”
  • Patient discharged to inpatient rehab facility after a 5 day LOS.

Question:   Are there any query opportunities based on the scenario stated above?

Discussion:

  • Acute postop pulmonary insufficiency is not a valid diagnosis when the postop care is part of regular routine care, i.e. patient remains on routine ventilator postop and extubated within 24 hours of surgery.
  • Consider a query for clarification when ventilator time exceeds the normal time based on surgery type or patient has to be re-intubated due to respiratory distress.
  • Acute postop pulmonary insufficiency does not have specific criteria. Therefore, use caution with this diagnosis which may trigger an inquiry by third party payers.
  • Consider a query for acute postop respiratory failure rather than acute postop pulmonary insufficiency using facility based guidelines when the patient meets clinical criteria.

UASI Recommends:

  • Query for validation of the diagnosis of acute postop pulmonary insufficiency.

Documentation without clarification:

Principal diagnosis: I2510-Atherosclerotic heart disease of native coronary artery without angina pectoris

Secondary diagnosis:

J961 Acute pulmonary insufficiency following thoracic surgery

I10 Essential hypertension

E119 Type 2 Diabetes mellitus without complications

Z794 Long term (current) use of insulin

E669 Obesity, unspecified

Z6834 Body mass index (BMI) 34.0-34.9, adult

E785 Hyperlipidemia, unspecified

Procedures:

021209W Bypass Coronary Artery, Three Arteries from Aorta with Autologous Venous Tissue, Open Approach

02100Z9 Bypass Coronary Artery, One Artery from Left Internal Mammary, Open Approach

06BP0ZZ Excision of Right Saphenous Vein, Open Approach

4A023N7 Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach

B2111ZZ Fluoroscopy of Multiple Coronary Arteries using Low Osmolar Contrast

These codes are not meant to be all inclusive, merely representative of a typical bypass.

DRG 233 Coronary Bypass w Cardiac Cath W MCC RW= 7.6377, SOI 2 ROM 1

Documentation with clarification:

Principal diagnosis: I2510-Atherosclerotic heart disease of native coronary artery without angina pectoris

Secondary diagnosis: 

I10 Essential hypertension

E119 Type 2 Diabetes mellitus without complications

Z794 Long term (current) use of insulin

E669 Obesity, unspecified

Z6834 Body mass index (BMI) 34.0-34.9, adult

E785 Hyperlipidemia, unspecified

Procedures:

021209W Bypass Coronary Artery, Three Arteries from Aorta with Autologous Venous Tissue, Open Approach

02100Z9 Bypass Coronary Artery, One Artery from Left Internal Mammary, Open Approach

06BP0ZZ Excision of Right Saphenous Vein, Open Approach

4A023N7 Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach

B2111ZZ Fluoroscopy of Multiple Coronary Arteries using Low Osmolar Contrast

These codes are not meant to be all inclusive, merely representative of a typical bypass.

DRG 234 Coronary Bypass w Cardiac Cath W/O MCC   RW=5.1472, SOI 1 ROM 1

The removal of acute postop pulmonary insufficiency following thoracic surgery will decrease RW as well as decrease the SOI from 2 to 1. This will remove the MCC, resulting in decreased reimbursement but will provide a more accurate depiction of the clinical picture; additionally, this will likely result in thwarting a potential denial for acute postop pulmonary insufficiency.          

CDI Educational Tips:

  • UASI recommends each facility establish time frames related to routine postop ventilator support for consistency.
  • Baseline status is important for the clinical validation of several diagnoses including acute pulmonary insufficiency/acute respiratory failure. It is imperative that these diagnoses be validated to ensure a complete clinical picture without the risk or appearance of upcoding.
  • Acute Postoperative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure is considered a post-op complication and can adversely affect quality scores.
  • Acute Postoperative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure will be an MCC but without clinical support is an improper DRG payment.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.  

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