Post-Op Respiratory Failure

Rationale

There is a lack of established precedent to follow for capturing acute respiratory failure (ARF) in pediatric patients undergoing heart surgery.

Background

Corrected congenital cardiac lesions often require mechanical ventilation to reduce work-load on a child's heart, allowing time for healing as well as systemic acclimation to reconfigured circulation/blood flow.  ARF is rarely a complication of the surgical procedure, rather it is expected in the usual course of recovery.

Coding guidelines dictate that when ARF is documented as “postoperative” or “following surgery,”  even if qualified with “incidental,”  “unavoidable,” or “expected,“ should be coded as a complication when indexed in ICD-10-CM.  While this does not necessarily imply improper or inadequate care, the labeling may still negatively impact facility quality measures.

Tips For Documentation

For patients undergoing cardiothoracic procedures who require mechanical intubation and ventilation after surgery, and have a usual course of clinical care:

  • Document “Acute Respiratory Failure”

  • Minimize potential for complication coding and do NOT write:

  • Unrelated to any surgical complications

  • Expected after CPB surgery

  • Post-operative respiratory failure

  • Coding may query for clarification if it seems that ARF may have been a surgical complication

Quick Tips!

Respiratory Failure is…

  • Hypoxemia: PaO250 mmHg

  • Support including:

    • O2≥4 L/min,

    • ≥30% FiO2

    • CPAP

    • BiPap

  • The terms “distress” and “insufficiency” only support Failure