Skilled Nursing Facility

Q&A: Querying for acute respiratory failure

Q: Acute respiratory failure is consistently one of our top denied diagnoses. We’ve tried to address common documentation errors through education but are still seeing issues. How can our CDI staff and coders create more effective queries for this condition?

A: The main reason I see for acute respiratory failure denials is a lack of clinical indicators. Appropriate treatment and not just two liters per of oxygen with complete resolution of symptoms can also lead to denials. Another common issue I’m seeing is with conflicting documentation. A patient may have a diagnosis of acute respiratory failure documented in their chart, but then the documentation also says “no respiratory distress noted” or that the patient is “breathing comfortably.”

Acute respiratory failure was our most frequent denial at my organization. We began a rather aggressive attempt to reduce this by providing more education and consistently issuing clinical validation queries. We included the clinical indicators and tried to impress upon our providers that a room air oxygen saturation of 89% with a respiratory rate of 20 that resolved with one nebulizer treatment or two liters per minute of nasal oxygen, does not really reflect the life-threatening condition of acute respiratory failure. We also included provider documentation that may include “alert and oriented, no distress noted” in our queries in an attempt to present the lack of clinical indicators.

In addition to traditional clinical validation queries, we’ve also had a great deal of success with queries for conflicting documentation. For example, if one physician documents acute respiratory failure, but another documents just hypoxia, we would send a conflicting documentation query.

For more information, see “CDI tips for top denied diagnoses” by Brian Simpson, MS, RRT, CCDS, CDIP, CCS, CRC, a CDI and risk adjustment specialist at Penn Highlands Healthcare in DuBois, Pennsylvania, in the January 2021 issue of HIM Briefings.