Clinical Documentation Improvement: Coding Acute Respiratory Failure

Appropriate use of the term “acute respiratory failure” has become a hot topic recently. Some well-meaning CDSs, billers and doctors have fallen into the trap of using the term in order to bill at a higher level. This is an especially timely topic with the advent of Value Based Purchasing. At a recent client site, the pulmonary intensivists were using the term 100% of the time in their post procedure patients on a ventilator. I met with these doctors the next morning during rounds. We saw 4 patients, three of which had no problems being weaned off the vent using standing orders. The fourth patient arrested during the night after being weaned from the ventilator and had to be re-intubated. The time the intensivists spent with the first three patients was very brief. The decision making and time spent with the fourth patient was obviously more intense. It was clear that the fourth patient had indeed had an episode of acute respiratory failure. The ventilator management of the other three patients was just an integral part of the procedure and therefore use of the term “acute respiratory failure” would be inappropriate. Rounding with these doctors was incredibly beneficial. This is a very effective way to resolve documentation issues; reviewing their patients’ charts in real time.

Kelli Estes, RN, CCDS