Documenting Acute Hypoxic Respiratory Failure and CHF to Prevent DRG Denials

There was a time when people took the word of a doctor at face value. If the doctor said, “This patient has hypoxia,” even if there was no evidence for it, then the patient had hypoxia. If the doctor said, “This patient has chronic heart failure,” then the patient had CHF. As we all know, those days are long gone.

Today, we must document the existence of a condition in our H&Ps, consults, progress notes, and discharge summaries. We are no longer just documenting so that other clinicians can appropriately care for our patients. Payers, third-party auditors, and physician advisors (like me) are also looking at our notes and, if there is no documented evidence for a diagnosis, then likely the hospital stay or DRG will be denied.

As a Sound Physician Advisor, I have written hundreds of appeal letters on behalf of our hospital partners. Many of these appeals are for DRG denials, where a third-party auditor has denied the DRG due to insufficient evidence in the record. And, contrary to how you might feel, the auditors are not acting arbitrarily. For the most part, they are thorough, going through the record in detail. When there is not enough evidence to support a diagnosis, the payer will deny the DRG. In order to avoid this, especially with highly complex and potentially life-threatening diagnoses like hypoxic respiratory failure or congestive heart failure, it is important to be very specific and detailed in your documentation.

Since hypoxia and CHF are two diagnoses that I work on quite often, let’s take a closer look at some of the factors that contribute to these DRG denials.

Hypoxia & Acute Hypoxic Respiratory Failure

Very frequently, payers will deny a DRG that includes “acute hypoxic respiratory failure” for lack of evidence in the record. When the charts come to me, I find that there is often no documented evidence for this diagnosis. Hypoxic respiratory failure is defined as oxygen saturation of less than 90%, regardless of whether a patient is receiving supplemental oxygen. Simply placing a patient on supplemental oxygen is not sufficient evidence for acute hypoxic respiratory failure.

There has to be concrete documentation of an oxygen saturation – either by pulse oximetry or on an arterial blood gas sample – that is less than 90%. This is a binary diagnosis. It is either present or absent. There is no in-between.

Some guidelines:

• The correct diagnosis for a patient who is not on chronic oxygen therapy and presents with oxygen saturation below 90% is acute hypoxic respiratory failure, not hypoxia.
• A patient on chronic oxygen therapy who requires more oxygen than their baseline level in order to keep oxygen saturation above 90% is experiencing acute hypoxic respiratory failure.

• Without documentation of either of these conditions, then there is no evidence of acute hypoxic respiratory failure. Period.

• You need to be clear on the definitions of hypoxia and acute hypoxic respiratory failure. Take time to review the pathophysiology.

Congestive Heart Failure (CHF)

With congestive heart failure DRG denials, the situation is different. CHF is not binary – it is quite complicated, and often the documentation is simply not specific enough. Is the patient systolic or diastolic? Is the CHF acute or chronic? Is the ejection fraction (EF) reduced or preserved? Often, I search through a record to try and defend the CHF DRG designation only to find that the patient had a clear lung exam, no hypoxia, a clear CXR, and yet the clinician wrote CHF. When documentation is this sparse, it is difficult to defend.

When you are treating a patient with CHF, remember:

• Detailed documentation is essential for CHF.
• Focus on providing details about both the acuity and chronicity, as well as the type of CHF.
• Detail the typical signs including crackles on lung exam, pulmonary edema on chest x-ray, hypoxic respiratory failure.
• If the typical markers are not present, then detail why you, as the clinician treating the patient, feel this patient does indeed have CHF.

By strengthening your documentation, you will help prevent denials and ensure that you get credit for the hard work you do every day. Your effort cannot prevent every DRG denial, but your detailed documentation will go a long way in supporting an appeal. More than ever before, clinicians and hospitals are on the same team, and good documentation by clinicians is an essential part of being a good partner in the care we deliver.