Health Information Management

News: OIG targets mechanical ventilation

CDI Strategies, April 11, 2013

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The OIG is taking a closer look at mechanical ventilation, according to its FY 2013 Work Plan. In particular, the Work Plan states the following:

We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. …For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.
The OIG, Recovery Auditors, and others are targeting MS-DRGs 003 and 004, 207, 870, 927, and 933, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc. in Fort Walton Beach, Fla. Physicians perform invasive ventilation for patients with acute respiratory failure who can’t breathe on their own, says Haik. However, acute respiratory failure may not be the principal diagnosis.
CDI specialists and coders must think carefully when coding—and querying for—acute respiratory failure, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, Wis. In particular, they shouldn’t ask physicians whether the patient had acute respiratory failure when documentation doesn’t include any clinical indicators for the condition.
“The patient may be on the vent prophylactically to protect the airways,” he says. For example, a patient who had a stroke and who has a propensity to aspirate may receive mechanical ventilation to prevent aspiration of stomach contents into the lungs. This patient doesn’t have acute respiratory failure, he adds.
Coders should use the following criteria as clinical indicators for acute respiratory failure in a patient whose lungs were previously normal:
  • PO2 < 60 mmHg
  • PCO2 > 50 mmHg
Coders can use either of the following criteria as clinical indicators for acute respiratory failure in a patient with previously abnormal lungs:
  •  pH < 7.35 with a PCO2 > 50 mmHg
  •  A change in the PO2 < 60 mmHg representing a drop of 15 mmHg from the previous normal PO2
“The duration of mechanical ventilation is highly scrutinized,” says Haik. CDI staff and coders shouldn’t solely rely on physician orders when calculating duration. Instead, they should also use respiratory therapy notes and progress notes, which sometimes span multiple days in the record.
“You have to know the exact hour that the patient is extubated,” says Haik. Physicians may write, time, and date an order for extubation, and the patient may not actually undergo the process until an hour or more later. “It’s not when the physician writes the order—it’s when the patient is extubated,” he adds.
Editor’s Note: This article was written by Lisa Eramo, a freelance writer and editor in Cranston, R.I., for

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