By Dr. Richard Pinson, MD, FACP, CCS
Q: What diagnoses could be compliantly used when a patient comes to the ICU on a ventilator from surgery and needs some more time to let the anesthesia wear off from a long OR time?
A: Any diagnosis submitted on a claim must meet the test of “clinical validity.” According to CMS: “Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record.”
Documentation of postprocedural respiratory failure or pulmonary insufficiency sometimes occurs when patients are mechanically ventilated for several hours following surgery. For clinical validity, the patient must have acute pulmonary dysfunction requiring non-routine measures and/or prolonged respiratory support. Clinicians may check for a PaO2/FIO2 <300 which would confirm acute hypoxemic respiratory failure on vent.
In an uncomplicated, routine, postoperative ventilator setting, the patient’s primary problem is usually some degree of depression of the brain’s respiratory center (code G93.89) during routine recovery from anesthesia and physiologic stress of surgery. Do not use “ventilator dependence” (Z99.11) reserved for patients who are chronically dependent on a ventilator.
The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.
Available online or hardcopy. Order both and save! Learn more here.
About the Author
Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.