Knowledge Base Article

Q:

What should we do when Acute Respiratory Failure is documented but the clinical signs and symptoms describing the patient do not reflect the severity of the diagnosis?

A:

Coders in this day and time have to know and be aware of more clinical factors than ever before. Look at the patient’s clinical presentation and what tests are performed. Below is a listing of just a few basic things MMP suggests looking for:

1.Documented signs / symptoms

• SOB (shortness of breath) / Respiratory distress
• Delirium and/or anxiety
• Pursed lips
• Syncope
• Use of accessory muscles
• Tachycardia
• Tachypnea
• Confusion
• Sleepiness
• Depressed consciousness
• Cyanosis (bluish color to skin, lips and/or fingernails)

2.Per Coding Clinic, Acute Respiratory Failure is supported as a diagnosis when at least 2 of the following critical values (ABG’s) are met.

• pH < 7.35
• PO2 < 60
• PCO2 > 50

Note: The above ABG levels may not apply to the patient with chronic lung disease (e.g., COPD). If a baseline PO2 is known, a decrease by 10mmHg or more indicates acute Hypoxic Respiratory Failure.

3.Type of oxygen treatment, i.e., oxygen via mask, Bipap, nasal cannula or vent?

4.Generally, patients are placed in ICU for close monitoring.

MMP recommends coding Acute Respiratory Failure if there are sufficient clinical indications and the physician has documented the diagnosis. Most importantly, if you don’t see sufficient clinical signs/symptoms/indicators documented, the physician should be queried for clarification. It is recommended that all clinical indications in the record and the type of treatment the patient received, be documented in the physician query.