Acute Pulmonary Insufficiency following Surgery

It’s not a valvular problem, but a definitional one.

I recently received an email from a clinical documentation integrity (CDI) friend from my previous life as a physician advisor, asking my opinion on acute pulmonary insufficiency. She pointed out that the Association of Clinical Documentation Integrity Specialists (ACDIS) CDI handbook says that “there presently are no defined diagnostic criteria published related to pulmonary insufficiency” and that “a literature search of this term describes incompetence or regurgitation of the pulmonary valve.” ACDIS’s advice is that documentation of pulmonary insufficiency would likely require further clarification from the provider.

Postprocedural respiratory failure is a major comorbid condition or complication (MCC), but it has the potential of triggering Patient Safety Indicator (PSI) 11, Postoperative Respiratory Failure. The components of PSI 11 are that there is acute respiratory failure, and it had its onset following and due to a complication of surgery (as opposed to arising from an underlying pulmonary condition, or being present on admission). Exclusions include being assigned into a Diagnostic-Related Group (DRG) in Major Diagnostic Category (MDC) 4, which comprises diseases and disorders of the respiratory system; belonging to the circulatory system, MDC 5; undergoing procedures prone to respiratory issues like laryngeal, craniofacial, esophageal, or lung surgery; and having certain neurological or neuromuscular disorders including dementia and critical illness myopathy.

ACDIS is correct when they say there are no defined diagnostic criteria, and a literature search of acute pulmonary insufficiency is unrewarding. In fact, when I researched this years ago, I contacted a pulmonologist friend of mine for insight. He told me that acute pulmonary insufficiency wasn’t really a clinical thing, and he couldn’t help me define it, because he didn’t really know what it was. I am confident that it is not intended to indicate pulmonary valve insufficiency, however.

In order to define it, I had to identify the root cause of the problem. My assessment is that intensivists feel obliged to use the diagnosis of acute postprocedural respiratory failure to justify why they are billing critical care for their professional evaluation and management (E&M) CPT code. In order to change the behavior, I had to give them a reasonable alternative that met medical necessity for critical care billing.

“Normal” is easy to recognize; consider a patient who has an uneventful wean from the ventilator, requiring no supplemental oxygen, and their oxygen saturation and/or blood gas and/or PaO2/FIO2 (P/F) ratio is normal. This is an uncomplicated postoperative course, and these patients do not meet medical necessity for critical care time.

Acute postprocedural respiratory failure is straightforward, too. Such a patient meets acute respiratory failure criteria such as pO2 < 60 mmHg, or pCO2 > 50 with a pH less than 7.35. These patients have high flow oxygen needs or require inordinate amounts of positive-end expiratory pressure (PEEP). Reintubation automatically triggers PSI 11, and inability to wean the patient within 48 hours also falls into the category of acute postprocedural respiratory failure.

I, therefore, concluded that acute pulmonary insufficiency following surgery was intermediate between normal and acute postprocedural respiratory failure. These might be patients who have an unexpectedly slow wean without exceeding 48 hours. They may have hypoxia, which does not cross the threshold of acute hypoxic respiratory failure, and may need judicious oxygen supplementation. Their P/F ratio is between 300 and 399. They may be modestly hypercapnic without exceeding 50 mmHg or becoming acidotic. These patients could have excessive secretions and require moderate pulmonary toilet, but they do not require reintubation.

How do you get providers to use a term that isn’t really a clinical thing? The same way you get them to use the term “functional quadriplegia.” Have them believe it serves a purpose for them or their patients, that it gives them a way to describe a legitimate clinical scenario, and they will buy in. A diagnosis of acute pulmonary insufficiency could justify critical care ventilation management for their pro fee, without getting them or the hospital dinged. There is the potential for life-threatening deterioration.

Educate providers to link respiratory failure to an alternate medical condition, if that is the etiology, like “acute hypoxic respiratory failure due to exacerbation of COPD.” Only postprocedural respiratory failure in the J95.82- subcategory triggers PSI 11, as opposed to J96 variants. Finally, educate them to use the term “acute pulmonary (not respiratory) insufficiency” if the patient doesn’t meet respiratory failure criteria.

The goal is to make the patient look as sick and complex in the medical record as they do in real life. They should tell the story – but tell the truth.

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 a.m. Eastern.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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