As we continue to evolve from fee-for-service to performance-driven health care, transparent quality and consumer value demand a cooperative integration of all stakeholders.
Simply put, quality of care is reflected by quality documentation. Complications of care delivery are defined as unexpected events or expected/integral conditions with unexpected resource utilization, and are directly linked to medical or surgical care by the treating physician. These conditions possess more than a temporal relationship but rather one of “cause and effect.” An important distinction must be made regarding a documented condition as being “postoperative.” In fact, most physicians would endorse that a “postoperative“ condition is simply one that occurs after the procedure is completed and not “due to” the procedure.
An example that often creates havoc among quality and clinical documentation teams is the documentation of “postoperative respiratory failure.”
The diagnosis of respiratory failure following surgery has profound regulatory and quality of care implications. If identified as “postop”, “due to”, or “complicating” a procedure, respiratory failure is classified as one of the most severe, life threatening, reportable surgical complications a patient can have. This diagnosis adversely affects quality scores for both the hospital and the surgeon.
On the other hand, the diagnosis and coding of post-procedural respiratory failure (an MCC) often results in large payment increases for hospitals. If improperly diagnosed without firm clinical grounds, it may become the basis for regulatory or contractual audits, penalties, sanctions, and even legal action affecting the hospital and the physician.
To validate the diagnosis, the patient must have acute pulmonary dysfunction requiring non-routine aggressive measures.
The answers to these questions will ensure the validity of the code assignment and the integrity of the coding database. ICD-10 has the ability to be more specific about the type of respiratory complication within the code itself. It includes the following:
When you receive a query from the CDI regarding this diagnosis, realize the reason it is being asked and see if this is acute respiratory failure due to a “complication”, or is it due to chronic condition, such as COPD, preexisting pulmonary or heart disease.