In order to maintain a consistent and cohesive revenue cycle for your hospital, clinic, or practice, an accurate medical coding system must be put into place. This requires that physicians provide medical coders with detailed patient documentation, including the appropriate descriptions and figures that justify their diagnoses. This allows coders to verify the code of their diagnoses and ensure that their healthcare institution bills patients and their providers, as well as obtain your reimbursements in a timely fashion. Moreover, with medical coding support services from ECLAT Health Solutions, you can receive excellent medical coding quality assurance that you can rely on. Our work has helped sustain healthcare institutions both big and small, from large hospital facilities to smaller clinics and practices across the country.
Below, we will discuss highlights from our latest Webinar on Addressing Respiratory Failure - Coding and Denials Management. We began by discussing the essential characteristics of respiratory distress and failure, as well as some guidelines medical coders should follow in discerning each patients’ diagnosis. We also dive into specific case studies indicating how coders should communicate with physicians and how to respond in case of a miscoded diagnosis. Read further to learn more!
The Clinical Lens: What is Respiratory Failure?
Before discussing how diagnosis relates to medical coding, let’s first define in clinical terms what respiratory failure is. Co-founder of the CDI-focused consulting firm, DCBA, Inc., Robert S. Gold, MD, stated that respiratory failure essentially means that “...the lungs cannot meet the needs of the body to supply oxygen and remove carbon dioxide.” This deteriorative condition leads to the development of several different symptoms, including:
- Slow breathing
- Abnormal sounds from the lungs
- Bradycardia or slower than average heart rate
- Failure to respond to others
- Cyanotic in appearance; i.e. a bluish-gray color around the skin, lips, nails, and around the eyes.
As a result of these symptoms, several physiological changes occur:
- Lower oxygen levels impact the heart. For example, a right-sided heart enlargement may cause a Cor pulmonale or cardiac failure of the heart’s right side.
- Lower oxygen may also cause organs to become ischemic, possibly leaving damage or permanent dysfunction of tissue.
- Enlarged/Engorged Liver
- Swelling of upper or lower extremities
- Irregular rhythm
- Higher risk of blood clots
For medical coders, both the descriptions of the symptoms and physiological changes are vital. They must be accurately conveyed by physicians through the highly-detailed medical documentation they produce and transmit to their respective coding specialists.
The Medical Coding Lens: Guidelines, Denial, & Prevention
Circumstance of Admission & Principal Diagnosis
On the other hand, once patient documentation is received by the medical coders, there are still several procedures that must be performed before finalizing them. For example, coders must first confirm the circumstances of admission with the physician that originally filed the documentation, particularly the principal diagnosis..
In the case of respiratory failure, if a patient was admitted with both that and another acute condition, such as myocardial infarction, CHF, or aspiration pneumonia, then the principal diagnosis would depend on the patient’s situation and what primarily caused their admission to the hospital.
However, if the physician did not make it clear within the documentation which of the two or so conditions was the principal diagnosis that was the reason for the patient’s admission, then the medical coder must make a query to the physician. They must confirm which condition was the stated purpose for the patient’s admission. There are strict guidelines regarding two or more diagnoses being the reason for admission (Section II, C).
There are also two additional requirements that a physician must meet in provided proper medical documentation. First, they must record the relationship between the treatment or procedure as a complication. Second, they must indicate a cause-and-effect relationship between the care provided and the condition. If either one or the other is missing, coders must query the physician to confirm the information.
It is also important to remember that not every condition that arises during or following surgery, as well after receiving medical care is considered a complication. Conditions that occur in the perioperative period, the time in which a patient is cared for before and after their surgical procedure, should be documented as a complication of the procedure. This should come with an explanation of the correlation between the surgery and the condition, such as drugs affecting how a patient breathes due to pre-existing chronic conditions. Finally, healthcare facilities should have a policy governing the coding of conditions, such as respiratory failure, not supported by clinical criteria in the medical record.
Choose Reliable Medical Coding Quality Assurance You Can Trust
The complexities offered by diagnoses such as respiratory failure challenges medical coders and other healthcare support services. With clear and open communication between them and your clinical staff, you can be assured that your hospital, clinic, or practice will be a smooth and efficient organization. At ECLAT Health Solutions, we provide medical coding quality assurance support as well as in clinical documentation improvement, all in an effort to ensure we provide the best of our team’s experienced medical coding quality assurance. We have worked with numerous healthcare organizations, both in large and small scale capacities. Our desire is to help your organization care for patients rather than for technical and administrative setbacks. Fill out our form or call us at 703-665-4499 for further information on our services.