HCPro, JustCoding Inpatient - 2021 Issue 5 (February)
Respiratory failure: Evaluate clinical indicators, query opportunities
February 2nd, 2021
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Article Overview
This premium article examines clinical indicators and documentation query opportunities related to respiratory failure in the inpatient setting. It focuses on acute respiratory failure, chronic respiratory failure, respiratory failure associated with surgical procedures, and ventilator-driven MS-DRG implications. The discussion is aimed at coders, CDI specialists, physician advisors, and auditors who work with complex respiratory diagnoses and principal diagnosis sequencing.
Why This Topic Matters
Respiratory failure cases can affect diagnosis coding, present-on-admission assessment, query practice, and MS-DRG assignment. Understanding the documentation issues discussed in the article helps teams evaluate record support for these high-impact inpatient cases.
Article Sections
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Acute respiratory failure
This section reviews documentation considerations for acute respiratory failure in the inpatient setting. It addresses common clinical indicators, query opportunities, and scenarios where provider clarification may be needed.
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Respiratory failure due to surgical procedures
This section discusses postoperative respiratory disorders and related documentation concerns. It also references risk-adjustment contexts and the need for clarification when postoperative respiratory terminology is uncertain.
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Ventilator MS-DRGs
This section covers how mechanical ventilation affects MS-DRG assignment in selected circumstances. It also discusses the documentation elements that may affect ventilator hour counting and related coding review.
What You Will Learn
- How inpatient documentation issues arise in cases involving respiratory failure
- Which broad clinical indicators are discussed for acute respiratory failure review
- Why provider queries may be needed for postoperative respiratory conditions
- How mechanical ventilation can affect MS-DRG grouping in certain scenarios
- Which documentation gaps may lead to coding or sequencing review
Who Should Read This
- Inpatient coders
- CDI specialists
- Physician advisors
- Coding auditors
- Clinical documentation integrity teams
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