respiratory failure: quality resuscitation · – define acute and chronic respiratory failure –...

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Robert J. Stein, MD, CCDSAssociate Director

Enjoin

Respiratory Failure: Quality Resuscitation

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Articulate the impact of respiratory failure on value‐based quality outcomes

– Define acute and chronic respiratory failure

– Identify clinical situations in which postoperative respiratory failure should not be coded

– Explain the impact of respiratory failure on quality metric targets

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Respiratory Failure

• The traditional focus on the capture of respiratory failure for MS‐DRGs

– Impact of acute respiratory failure as PDx

– Impact of acute respiratory failure as ODx (MCC)

– Impact of chronic respiratory failure as ODx (CC)


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Pay‐for‐Performance

• Pay‐for‐performance (“P4P”) is a term that describes healthcare payment systems that offer financial rewards to providers who achieve, improve, or exceed their performance on specified quality and cost measures

• Simply stated: Performance for quality and cost outcome measures which is lower than established standards will lead to a decrease in payments from Medicare for health systems and other healthcare providers

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• Move away from payment for volume

• Improve care coordination

• Promote alignment of financial and other incentives to increase the quality of care and lead to better outcomes

Value‐Based Payments and CDICMS Transition to Value‐Based Payments

HHS Secretary Burwell Posting January 2015

Goals: Increase % of Medicare provider payments in alternative payment models which tie payment to how well providers care for patients• 30% by 2016• 50% by 2018

Lowercost

Improve quality

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• Hospital pay‐for‐performance programs

ICD codes on submitted claims impact performance for the following outcomes:• Patient Safety Indicator (PSI) 90• Risk standardized mortality rates• Risk standardized readmission rates• Risk standardized THA/TKA complication rates• Medicare spending per beneficiary (MSPB)

Value‐Based Payments and CDI The Impact of Value‐Based Payments on Revenue

FY HACRP HVBP HRRP Overall

2015 1.00% 1.50% 3.00% 5.50%

2016 1.00% 1.75% 3.00% 5.75%

2017 1.00% 2.00% 3.00% 6.00%


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P4P ExampleValue‐Based Purchasing Program (HVBP)

• The Hospital Value‐Based Purchasing (VBP) Program is a Centers for Medicare & Medicaid Services (CMS) initiative that rewards acute care hospitals with incentive payments for the quality of care they provide to Medicare fee‐for‐service beneficiary inpatient encounters

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Key Concepts: HVBP

Initiated FY 2013 IPPS (Section 1886(o) of the Affordable Care Act).

Overview Rewards or penalizes hospitals for risk‐adjusted performance of a variety of domains, which include patient satisfaction, clinical care, safety, and efficiency. Built on the Inpatient Quality Reporting Program infrastructure. Traditional Medicare inpatient discharges.

Performance for defined measures is risk adjusted and compared to prior hospital performance and national performance. Hospitals that meet established performance standards receive incentive payments.

Financial impact

A 1.75% reduction (FY 2016) in the base operating DRG payment for each discharge funds the incentive pool. Payment reductions will increase by 25% per year until reaching 2% in FY 2017. Revenue neutral.

Public reporting

Information will be posted on CMS Hospital Compare.

Applicable hospitals

Includes those defined by section 1886, excluding those with IQR payment reductions, cited care deficiencies, without required minimum number of cases.

Annual updates

Financial impact (through 2017), measures, measure specifications & risk adjustment, time periods, scoring.

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FY 2016 Domain Weights & Measures

• Patient‐ and caregiver‐centered experience of care/care coordination

– Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

• Clinical process of care

• Outcomes

• Efficiency– MSPB‐1

Outcome

Patient experience of care: 25%

Clinical process of care: 10%

Outcome: 40%

Efficiency: 25%

Domain weights

o AMI‐7a o SCIP‐Inf‐9

o PN‐6 o SCIP‐Card‐2

o SCIP‐Inf‐2 o SCIP‐VTE‐2

o SCIP‐Inf‐3 o IMM‐2

o Mort‐30‐AMI o CLABSI

o Mort‐30‐HF o CAUTI*

o Mort‐30‐PNA o SSI*: Colon & Abd, Hysterectomy

o AHRQ PSI‐90


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FY 2017 Domain Weights & Measures

• Patient‐ and caregiver‐centered experience of care/care coordination

– Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

• Clinical process of care

• Safety

• Outcomes

• Efficiency– MSPB‐1

Outcome

Domain weights

o AMI‐7a o IMM‐2 o PC‐01

o Mort‐30‐AMI o Mort‐30‐PNA

o Mort‐30‐HF

Patient experience of care: 25%

Safety: 20%

Outcomes: 25%

Efficiency: 25%

Clinical process of care: 5%

o PSI‐90 o CLABSI o MRSA

o MRSA o CAUTI* o C. diff

o SSI: Colon & Abd, Hysterectomy

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HVBP – Respiratory FailureImpact on HF Mortality Outcomes

• Selection of discharges included in the cohort

Source: CMS Quality Net

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HVBP – Respiratory FailureImpact on HF Mortality Outcomes (cont.)

• Risk adjustment of discharges included in the cohort

4.93%

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% 20.00%

MALNUTRITION…

LIVERDIS

PNEUMONIA

RENAL_FAILURE

CARDIO_RESPIRATORY…

COPD

HTN (variation 1)

HXPCI…

PARALYSIS_FUNCTDIS…

TRAUMA

VASDIS_WCOMP…

Comorbidity Category Groups with top 90% of Risk Adjustment ImpactCHF Risk Standardized Morality


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• Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012

P4P ExampleHospital Readmissions Reduction Program (HRRP)

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Overview Penalizes hospitals for excess readmissions for selected conditions. Traditional Medicare inpatient discharges.

Risk-adjusted all-cause readmissions within 30 days are compared to the national mean for defined diagnoses and/or procedures. Excludes planned readmissions. Payment for excess readmissions is recouped through a reduction in DRG payment for all discharges.

Financial impact

Since inception: The lesser of dollars calculated for the hospital’s excess readmission ratio or the 3% floor. The reduction in payments is taken from the base operating DRG payment amount for each traditional Medicare discharge on a per claim basis.


Applies to most short-term acute care hospitals paid under the IPPS.

Annual updates

Applicable conditions, measure specifications, risk adjustment variables and coefficients, planned readmission algorithm, scoring, time periods.

Key Concepts: HRRP

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HRRP Applicable Populations

Measures Effective FY Mincases

HF 2013 25

AMI 2013 25

PNA 2013 25

COPD 2015 (FY 2014 IPPS rule) 25

THA/TKA 2015 (FY 2014 IPPS rule) 25

CABG 2017 (FY 2015 IPPS rule) 25

FY 2016 IPPS final rule – significant change

Fiscal year Applicable period

FY 2015 July 1, 2010–June 30, 2013

FY 2016 July 1, 2011–June 30, 2014


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HRRP – Respiratory FailureImpact on PNA Readmission Outcomes

• Risk adjustment of discharges included in the cohort

8.72%

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00%

ESRD_DIALYSIS

HEMATOLOGICAL…

CARDIO_RESPIRATORY

COPD

DECUBITUS_ULCER

MALNUTRITION…RENAL_FAILURE

CHF

POLYNEUROPATHY

PNEUMONIA

MAJOR_PSYCH…

DIABETES

DEMENTIA

VASDIS_WCOMP…

ARRHYTHMIAS

Comorbidity Category Groups with top 90% of Risk Adjustment ImpactCABG Risk Standardized Readmissions

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Initiated 2014 IPPS Final Rule (Section 3008 of the Affordable Care Act).

Overview Penalizes hospitals with poor performance for hospital acquired patient safety events. Traditional Medicare inpatient discharges.

Performance is risk adjusted and ranked against other hospitals. Hospitals in the top (worst) quartile are financially penalized. (This program is in addition to those in the Deficit Reduction Act [DRA] or “nonpayment” HAC program.)

Financial impact

FY 2016: 1% reduction in DRG payments for all traditional Medicare discharges. Payment reduction takes place after adjustments for HRRP & HVBP; reduction is not limited to base DRG payments but includes add-ons (IME, DSH).

Public reporting

Information will be posted on CMS Hospital Compare.


Most short term hospitals paid under IPPS which meet specified criteria (Section 1886(p)(2)(A) of the Affordable Care Act).

Annualupdates

Measure specifications, risk adjustment, time periods, scoring.

HACRP – Key Concepts

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AHRQ PSI‐90 Overview

• A weighted composite of 11 Patient Safety Indicators

• Use of a composite:

– Increases statistical precision due to increased sample size

– Supports issue of competing priorities where more than one component measure may be important

– Assists consumers in selecting healthcare, providers in allocating resources, payers in assessing performance

AHRQ PSI‐90 measure

3 Pressure ulcer 11 Postoperative respiratory failure

6 Iatrogenic pneumothorax 12 Periop PE or DVT

7 CLABSI 13 Postop sepsis

8 Postop hip fracture 14 Postop wound dehiscence

9 Periop hemorrhage/hematoma 15 Accidental puncture/laceration

10 Postop physiologic & metabolic derangement


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CMS Modifications – PSI‐90

• Excludes 3 of the PSIs in the AHRQ PSI‐90 Composite*

– 9 Perioperative hemorrhage/hematoma

– 10 Postop physiologic & metabolic derangement

– 11 Postop respiratory failure

• Refines statistical methodologies (“smoothed rate”) to account for Medicare population characteristics

CMS PSI‐90 Measure

3 Pressure ulcer 12 Periop PE or DVT

6 Iatrogenic pneumothorax 13 Postop sepsis

7 CLABSI 14 Postop wound dehiscence

8 Postop hip fracture 15 Accidental puncture/laceration

*PSI‐90 is currently undergoing NQF maintenance review

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Respiratory Failure

• Accurate documentation and code assignment has always been important … now code assignment is linked to quality initiatives that have further impact on financial bottom line as well as perceived quality of care on the patient population in your community

• Respiratory failure is linked to many of the quality measures outlined by CMS

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Quality of Care Is Quality of Documentation

Readmission & Mortality & Complication & Cost

PER

Case Complexity

Documentation Coding(Physician)


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Acute Respiratory Failure

There is not a uniform definition of acute respiratory failure. Clearly, abnormal gas exchange is the crux of the condition. Acute respiratory failure is at the end of

a continuum starting with dyspnea followed by hypoxemia and progressing to severely abnormal gas exchange, which is potentially a life‐threatening

disorder requiring aggressive management and monitoring.

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Respiratory Failure

Failure of:

1. Transfer of oxygen across alveolar‐capillary membrane

2. Transport of oxygen to tissues

3. Removal of carbon dioxide from blood

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Respiratory Failure

https://en.wikipedia.org/wiki/Lung#/media/File:Alveoli.svg


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Respiratory Failure: “Respiratory System”

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Respiratory Failure

Type I: Hypoxemic

• Decreased PO2 (defined by PaO2 or SPO2 levels below the predicted levels to be normal for the age group with normal PaCO2 and normal or elevated pH level

Type II: Hypercapnic

• Increased PaCO2 and decreased pH level with/without decreased PaO2

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Acute Respiratory Failure

Clinical guidelines

• Abnormal gas exchange (ABG, VBG, SaO2, SPO2)

• Supplemental O2

• Increased work of breathing

• Increased use of hospital resources


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Respiratory Failure: ABGs

Normal values

• pH 7.35–7.45

• PCO2 35–45 mmHg

• PO2: Resting PaO2 > 80 mmHg and SaO2 > 95%

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Respiratory Failure: VBG

What about venous blood gases?

• Do not use PVO2 (no practical value)

• PVCO2 and pH are useful to assess ventilation and/or acid‐base status

• SVO2 may be used to guide fluid resuscitation during septic shock (central or mixed venous sample)

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Respiratory Failure: VBG

• Peripheral venous pH – 0.02 to 0.04 pH units lower than arterial pH

• Venous PCO2 – 3 to 8 mm higher

*** Cannot be relied upon in hemodynamically unstable patients


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Pulse Oximetry

SPO2 – the 5th vital sign

• Normal values

– Reasonably accurate between 70%–100%. Clinical cut‐off around 80% or about PaO2 of 50 mmHg.

• Pitfalls

– Does not assess ventilation (PCO2).

– Motion artifact/malposition: Bad data in = bad data out …look at waveform!!

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Acute/Chronic Respiratory Failure: ABGs/SPO2

Normal lungs

• Arterial blood PO2 level < 60 mmHg or a O2 saturation of < 90% on room air

Or

• Arterial blood PCO2 > 50 mmHg PH <= 7.34

Or

• PO2/FIO2 < 300 mmHg

Preexisting lung disease

• Change from baseline pO2 level by 10–15 mm

• Arterial blood PCO2 > 50 mmHg PH <= 7.34

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Respiratory Failure

Clinical presentation

• Evidence of increased work of breathing

– Rapid respiratory rate

– Use of accessory muscles of respiration and/or paradoxical breathing

Treatment

• Respiratory therapy

• Mechanical ventilation, CPAP/BiPAP, heated high flow O2, traditional O2

• Treatment of underlying cause (steroids, antibiotics, diuretics)


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Postoperative Respiratory Failure & Pulmonary Insufficiency

• Definition

• Indicators

• Common conditions

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Respiratory Failure – Postoperative Complications

• Not clinically significant for reporting purposes if isolated physical, radiographic, or laboratory finding

– e.g., incidental atelectasis on chest x‐ray, not requiring intervention

• This term should only be documented if there is a direct “cause and effect” relationship between the surgery and the condition

– e.g., DVT due to a liver transplant three days earlier

• There are special codes to delineate those conditions specified by MD as “postoperative”

– e.g., postoperative hemorrhage

• Everything which happens after surgery is “temporally” related, but not everything is a complication “due to” the surgery

– e.g., atelectasis after bowel resection

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Postoperative Respiratory Failure

Intraoperative and postprocedural complications and disorders of the respiratory system

• J95.1 Acute pulmonary insufficiency following thoracic surgery

• J95.2 Acute pulmonary insufficiency following nonthoracic surgery

• J95.3 Chronic pulmonary insufficiency following surgery

• J95.821 Acute postprocedural respiratory failure

• J95.822 Acute and chronic postprocedural respiratory failure


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Acute/chronic postoperative pulmonary insufficiency & acute/chronic postprocedural respiratory failure –similar pathophysiology and clinical indicators as in acute respiratory failure unrelated to surgery

• Location w/in “respiratory system”

• Measures of gas exchange

• Clinical presentation

• Evaluation and treatment

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• Acute postoperative pulmonary insufficiency …??

• 75‐year‐old morbidly obese man with COPD and OSA remained intubated for 24 hours following cholecystectomy. He was seen by the pulmonary consultant in PACU who documented “VDRF” in the record. Albuterol MDI per “Vent” protocol was ordered. On POD #1 following a successful SBT the patient was liberated from MV without difficulty. He was maintained on 2L O2 and his usual CPAP at hs.A. J95.2 Acute pulmonary insufficiency following nonthoracic

surgery

B. J95.821 Acute postprocedural respiratory failure

C. J96.00 Acute respiratory failure, unspecified

D. None of the above

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• Postoperative acute respiratory failure often defined as the need for assisted ventilation for more than 48 hours after surgery or unplanned reintubation. (CC, Fourth Quarter 2011, p. 123)

• Postoperative acute pulmonary insufficiency can be defined as a condition which requires O2 supplementation and intensified observation as a result of the procedure, with perhaps less significant gas exchange abnormalities than seen in acute respiratory failure.

• Under normal circumstances, MV used during a surgical procedure and immediately postoperatively is not coded separately. If the patient remains on MV several days (more than 2) postsurgery and provider documents an unexpected “extended” period of MV, then MV should be reported. (CC, Fourth Quarter 2014, p. 3 & Third Quarter 2004, p. 11) Coding postoperative respiratory failure should follow similar logic.


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• Do not assign acute postoperative respiratory failure following surgery if the respiratory failure is due to a preexisting or other underlying condition (COPD, CHF, pneumothorax)

• In the above scenario, assign acute or acute on chronic respiratory failure

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Postoperative Respiratory Failure – Answer D

• Respiratory failure was not validated by documentation of acute pulmonary dysfunction or further specific evaluation and treatment

• Remember: Depending on code assignment, this could be classified as a major complication of care, which will adversely affect quality scores and PSI

• This scenario has been addressed by Coding Clinic

• Consider a query for clarification or escalating this to the physician advisor or appropriate individual regarding its clarification prior to final billing

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Acute Postoperative Respiratory Failure and Pulmonary Insufficiency – Common Conditions

• Airway obstruction

• AECOPD

• Air leak

• Atelectasis

• Hemorrhage

• Ileus/gastric distention

• Pneumonia

• Pneumothorax

• Postoperative pain

• PE


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Respiratory Failure and Quality Metric Targets

• Clinical examples:

– AECOPD

– CHF

– Postoperative pulmonary emboli

– Iatrogenic pneumothorax

– Pneumonia

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Sequencing of Interrelated and CoequalConditions

• Two or more conditions may equally meet the definition of principal diagnosis. These two conditions may be:

– Co‐equal – unrelated, but occurring coincidentally

– Interrelated – characteristic manifestation associated with a specific condition

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Sequencing of Interrelated and CoequalConditions

• What determines the principal diagnosis selection?

– Circumstances of the admission

– Scope of care

– Diagnostic workup

– Therapy/treatment provided

– Tabular List or Alphabetic Index


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Sequencing of Interrelated and Coequal Conditions

– Specific ICD‐10‐CM conventions and the official interpretation of those conventions will also mandate the selection of the principal diagnosis.

– With regard to acute respiratory failure as principal diagnosis, chapter‐specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

– If, however, despite existing guidelines, no clear‐cut diagnosis emerges as a principal diagnosis, any of the diagnoses may be sequenced first.

– If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

ICD‐10‐CM Official Guidelines Section 1.C.10.b.1 and Section 1.C.10.b.3

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Clinical Example

Acute respiratory failure—coequal, Pdx?

This patient was admitted with COPD exacerbation and presented with an SPO2 of 77% on RA with a respiratory rate of 25. The patient was placed on 4L and SPO2 was 83%; patient was placed on BiPAP. ABGs on BiPAP – pH of 7.41, pCO2 of 35, and pO2 of 57 with SAO2 of 89.7%. The patient was also noted in ER to have "pursed lip" breathing. Patient was admitted to ICU on BiPAP, IV solumedrol, nebulized albuterol, and PO Azithromycin. Can the patient's condition be further specified as:

• Acute respiratory failure

• Hypoxemia only

• Other, please specify: _____________

• Unable to provide any additional information

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Clinical Example

• Acute respiratory failure?

• This patient was admitted with COPD exacerbation. Admit SPO2 83% RA. Respirations: 16. No accessory muscle use noted, no distress. He was placed on 2LO2. ABGs: 7.50, 25, 73, 96% on 2L; PF ratio 348.


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Clinical Example

• CHF and RF coequal?

• This patient was admitted with CHF, COPD exacerbation, and

acute on chronic respiratory failure. ABGs 7.31/62/60 on 2L.

Treatment was provided with IV steroids, nebulizers, and BiPAP.

BNP: 250. 1+ pedal edema noted. CXR: Blunted right

costophrenic angle. Lasix 20 mg PO ordered. Patient was

admitted to ICU, pulmonary consult requested, maintained on

BiPAP for 24 hrs and eventually weaned to nasal cannula.

• Resequence acute on chronic respiratory failure J96.22 as Pdx

in place of CHF (focus of care – correcting respiratory failure).

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Clinical Example

• Coequal?

• The patient presented with acute respiratory failure due to acute on chronic systolic heart failure. He had a pulse oximetry of 72% on room air. ABG showed pH 7.263. He was intubated and placed on mechanical ventilation. He was treated with IV NTG and IV Lasix. Heart catheterization was done. Medical treatment was suggested.

• Coequal? Yes.

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Clinical Example

• Postoperative complication? Acute respiratory failure?

• Patient developed pleuritic chest pain and increasing dyspnea with hypoxemia 2 days after LUL lobectomy for lung cancer.

• RA SPO2 90%. ABGs: 7.44/40/95 on 2L nasal O2. RR 20, noaccessory muscle use. CTA revealed LLL pulmonary emboli.

• Treatment: IV Heparin was started. O2 continued at 2L/m.

• D/C summary: “Patient developed hypoxemia and pulmonary emboli s/p lobectomy.” D/C medications: Xarelto, Norco.

• Consider T81.718A, (with PE, I26.99, as Odx) Complication of other artery following a procedure, not elsewhere classified, initial encounter, as principal diagnosis.


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Clinical Example

Query the physician as follows:

• The patient presented with a pulmonary embolism “status post lobectomy.” Can the condition be further specified as:

• Postop pulmonary embolism

• Pulmonary embolism unrelated to surgery

• Other: __________

• Unable to provide any further information

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Clinical Example

Respiratory failure—pneumothorax coequal conditions?

Acute postoperative respiratory failure?

Patient admitted with spontaneous pneumothorax. Admission ABGs 7.45/35/86.

He underwent a VATS procedure with excision of multiple blebs. In PACU, surgical progress note describes O2 desaturation to 86% with accessory muscle use and RR 28/m. Oxygen increased to 6 L with improvement in SPO2 to 95%. CXR – NO PTX. Transferred to telemetry and weaned from O2 on POD #3.

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Clinical Example

Query the physician as follows:

• Patient admitted with right‐sided spontaneous pneumothorax. ABGs on admit: pH 7.45, pCO2 33, p02 86. Placed on 2L O2. Admitted to med‐surg bed. He had two chest tubes placed. He underwent a VATS procedure with excision multiple blebs. In the PACU, oxygen was increased to 6 L per mask after SPO2 dropped to 86%. CXR: No PTX. Surgical progress note describes O2 desaturation with accessory muscle use and RR 28. Oxygen continued at 6 L with improvement in SPO2 to 95%. Transferred to telemetry and weaned from O2 on POD #3.


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Clinical Example

After study, can you further specify the respiratory condition following surgery as:

• Postoperative acute pulmonary insufficiency

• Postoperative hypoxia only

• Other, please specify: ________________

• Unable to provide further information

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Clinical Example – Coequal Conditions

Consider acute on chronic respiratory failure, J96.20, as a coequal condition

Query MD: Following outpatient PM placement, patient was admitted with iatrogenic pneumothorax. H/O chronic respiratory failure, on 2L continuous O2 at home. Patient was noted to have SPO2 of 87% on 5L with respiratory rate of 23. Patient was admitted to ICU and placed on 15 L NRB with PaO2 of 170, RR of 27, F/U CXR and ABGs ordered. Can the patient’s respiratory condition be further specified as:

• Acute on chronic respiratory failure

• Chronic respiratory failure only

• Other, please specify: ________________

• Unable to determine

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Clinical Example

Patient noted to have productive cough and dyspnea. SPO2 83% on RA. RR: 30. ABGs on BiPAP 100% 7.38/38/95. CXR: LLL consolidation. WBC: 23K. Following blood cultures, placed on Levaquin 750 mg IV q day. Admitted to MICU on BIPAP. Physician documented pneumonia and respiratory failure at d/c.

• Principal diagnosis(s)

• Co‐equal

• SOFA

• Impact on P4P


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Thank you. Questions?

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respiratory failure: quality resuscitation · – define acute and chronic respiratory failure –...

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