Battling the Winds of Denial: Avoiding Payment Reductions for Acute Respiratory Failure
March is windy, and the rapidly changing weather can take your breath away. The ICD-10 codes that catch the most downdrafts are J69.01 and J96.21.
The Challenge of Acute Respiratory Failure Denials
Acute respiratory failure, whether hypoxic or hypercapnic, is a serious and life-threatening condition often seen in patients with heart and lung disease admitted to acute care hospitals. Patient symptoms, clinical observations, abnormal peripheral oxygen saturation values, and abnormal arterial and venous blood gases are used to validate the diagnosis. So, why is acute respiratory failure, a major complication and comorbidity (MCC), consistently in the top five MCCs that Medicare Advantage companies deny payment for, resulting in a decrease in payment for the MS-DRG?
Defining Acute Respiratory Failure: A Cloudy Forecast
There’s turbulence surrounding the clinical criteria that validates a diagnosis of acute respiratory failure. Theres no universally agreed-upon definition for acute respiratory failure. Abnormal gas exchange determined by abnormal arterial or venous blood gas values is objective, and agreement on what these values mean is widely accepted. The challenge lies in the subjective part of the diagnosis. What does the clinical documentation say about the patient’s appearance? What do the peripheral oxygen saturation values mean for the patient?
Avoiding Denials: What Can You Do?
When the wind is stirring up the dust and reducing your visibility, what can you do to avoid payment denial for acute respiratory failure?
Medicare Advantage companies do not widely publicize their criteria for clinical validation, but from Enjoin’s experience in denial defense, we have insight into the clinical validation criteria being used by these companies for a diagnosis of acute respiratory failure. The components are documentation about the patient’s appearance, the patient’s expressed symptoms, lab values, and treatment. Let the dust settle and look at each component.
Key Components for Clinical Validation
The patient needs to be described as in distress, and this is more than just tachypnea. Common clinical terms that point to severe respiratory distress include the use of accessory muscles, tripoding, and inability to speak in complete sentences. If the patient says they are short of breath or, even better, states that they are struggling to breathe, document the patient’s expressed symptoms. How hypoxic is the patient? This needs to be part of the clinical documentation. Not every patient needs or will have an arterial blood gas, but they all will have measurements of their peripheral oxygen saturation. Document what this value means for the patient. It is common for patients to be placed on oxygen before any measurements are taken; document that the patient requires oxygen to correct their life-threating hypoxia.
Common Denial Patterns
Enjoin sees routine denials of payment for acute respiratory failure when the patient’s clinical description does not indicate respiratory distress, and the oxygen delivery is not at or above 4 liters of binasal oxygen. This may not align with the definition of acute respiratory failure use in your hospital. Medicare Advantage companies are using their definitions. To reduce the number of denials you receive for acute respiratory failure, be aware of the MA criteria.
An Exception: Hypercapnic Respiratory Failure
An exception: Acute or acute on chronic hypercapnic respiratory failure is a diagnosis established by an arterial or venous blood gas. Many patients with acute hypercapnic respiratory failure do not complain of being short of breath or show the typical findings of respiratory distress. They may need only low oxygen flow to correct their hypoxemia. This is why the ABG or VBG is critical to validating the diagnosis. Link the arterial or venous blood gas results to the diagnosis or acute or acute on chronic hypercapnic respiratory failure.
What Ai Says About Clinical Validation for Medicare Advantage
What does Artificial Intelligence have to say about establishing the clinical diagnosis of acute respiratory failure for a Medicare Advantage company?
The question: Create a case scenario of a patient with acute hypoxic respiratory failure and a diagnosis of acute hypoxic respiratory failure that a Medicare Advantage company will pay for.
The response included the following: Medicare Advantage company approves payment for the diagnosis of acute hypoxic respiratory failure based on the following criteria:
- ABG Documentation: The ABG results clearly indicate significant hypoxemia with Pa02 of 50 mmHg on room air.
- Oxygen Therapy: The patient required high-flow oxygen therapy via a non-rebreather mask, demonstrating the severity of the hypoxemia.
- Clinical Indicators: The patient exhibited severed signs of respiratory distress, including the use of accessory muscles and a significantly low oxygen saturation level.
- Comprehensive Documentation: Detailed documentation of the patient’s clinical status, investigations, and response to treatment supports the diagnosis.
Strengthening Documentation to Prevent Denials
Avoid unpleasant gusts of wind in March. Communicate with your doctors using the information you have from payment denials for the diagnosis of acute respiratory failure so they can document a clinical description of a patient that will avoid denial of payment. Don’t let denials sweep away your reimbursement—document with precision and awareness.