Thread by @Dr_Oubre

Insurances are REJECTING your diagnoses.

Especially "respiratory failure."

Bullet proof your diagnosis:

The problem?

🔶 A doctor's diagnosis should be the diagnosis. Period.
🔶 But diagnoses determine how much insurances pay hospitals
🔶 So insurances have their own (varying) criteria
🔶 There is not one set definition / criteria for respiratory failure

Let's dig in ⤵️

First, your institution may have their own criteria for respiratory failure.

Ask your CDI department if they have an institutional definition.

If not, this thread describes the general criteria that are expected.

But first, some misconceptions...

🔶 It is NOT only for people who are intubated.
🔶 "Acute Respiratory Distress" = SYMPTOM ≠ resp failure.
🔶 Routine intubation for surgery is NOT considered respiratory failure.

Okay, so general criteria...

THREE expected elements:

Put simply, these patients should be SICK.

They must have:
1️⃣ Altered Gas Exchange
2️⃣ Acutely symptomatic
3️⃣ Require high levels of respiratory support

Let's break those down...

1️⃣ Altered Gas Exchange

Hypoxic respiratory failure
🔶 SpO2 <91% on room air / home O2 or
🔶 P/F ratio <300 or
🔶 2L or more over baseline O2 requirement or
🔶 pO2 < 60 mmHg

Hypercapnic respiratory failure
🔶 pCO2 > 50 with pH <7.35 or
🔶 pCO2 > 10 over baseline with pH <7.35

2️⃣ Acutely symptomatic

They must exhibit respiratory distress and this MUST be documented.

Ex:
🔶 Tachypnea (RR > 20) or Bradypnea (RR < 10)
🔶 Use of accessory muscles
🔶 Inability to speak in complete sentences, etc

But there's a problem...

Patients are typically stabilized / no longer in distress by time of admission.

This SHOULD be documented by the ER doctor... but that's... unreliable.

The LACK of documented respiratory distress is a TOP reason for denial by insurance companies.

So how can you document it?

🔶 Physical exam if still in distress
🔶 Document discussion with ER doc indicating distress
🔶 Check vitals & document tachypnea in A/P.

Auto populated "No respiratory distress" in templates is often a source of denial.

https://twitter.com/2284420200/status/1573666164332527619

3️⃣ Treatment

This is NOT well defined.

At the very least, they NEED to be on supplemental oxygen.

A minimum is likely 3L NC, but this is not black & white.

But there are nuances…

🤨 At lower levels of supplemental O2, the other elements become more important (distress, level of SpO2, etc).

🤔At higher levels of O2, other elements become less important
(Pt requiring intubation is obviously in respiratory failure).

🧐 I don’t like this definition. There are examples I can think of that DON’T fit these criteria.

Call it respiratory failure if you think it is.

But the takeaway point is:

🌟Not all hypoxia = respiratory failure🌟

In summary:

Not all hypoxia = respiratory failure

Patients must be:

1️⃣ Hypoxic or hypercapnic
2️⃣ Symptomatic / in respiratory distress (document this SOMEWHERE)
3️⃣ Receiving significant respiratory support (no hard rule on O2 level)

I’ve left some things out for simplicity.
This is a highly nuanced topic.
Discuss below!

That's a wrap!

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