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

• Not all hypoxemia = Respiratory Failure

Your institution may have their own criteria for respiratory failure. 

Ask your CDI department if they have an institutional definition. 

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

But first,

Misconceptions

• It is NOT only for people who are intubated.

• You do not need an ABG.

• “Acute Respiratory Distress” = SYMPTOM ≠ resp failure.

• Routine intubation for surgery is NOT considered respiratory failure.

General Criteria

Put simply, these patients should be SICK. 

THREE expected elements:

They must have:

1. Altered Gas Exchange

2. Acutely symptomatic

3. 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

• Tripoding, etc

But there’s a problem…

Patients are typically stabilized / no longer in distress by time the admitting doctor is seeing the patient.

This ideally 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.

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 high flow nasal cannula is obviously in respiratory failure).

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

In the end, 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: 

1. Hypoxic or hypercapnic

2. Symptomatic / in respiratory distress (document this SOMEWHERE)

3. Receiving significant respiratory support (no hard rule on O2 level)

Question / Answer

“What do I NEED to document?”

• Technically, the one thing you NEED to document (in addition to the diagnosis of course) is the respiratory distress

• You do not HAVE to document the hypoxia, treatment, etc. However, if you DO, it makes the diagnosis iron-clad and practically impossible for insurances to deny

• Coders (who are non-clinical) code your diagnosis without question. It will only be called into question in two circumstances:

1. A CDI (typically a nurse) seeks clinical validation to ensure integrity or to prevent denial

2. An insurance denies the claim and your appeals / denial department will search the chart for the above criteria and make an argument that it is legitimate. If the above criteria are not present, they may not appeal the denial.

“At what point in my evaluation should my physical exam reflect?”

• Your physical exam in your note does not have to reflect the patient’s condition at the time of note writing / latest exam findings

• If initially the patient was dyspneic, you treated them and they improved, and you wrote your note after, then describe the dyspnea.

“What about the surgical patient that remains intubated due to hemodynamic instability during surgery?”

• If the only issue is hemodynamic instability, then I would not document respiratory failure.

“What about the patient who is "intubated for airway protection.”

• This is not black / white and highly debated. Consider this on a case-by-case basis… I hesitate to even comment on this.

• A patient who is intubated because they needed precedex or propofol for agitation? Probably not.

• Patient who is intubated because of a drug overdose but they are not hypoxic or hypercapnic…yet. By the above criteria, they do not meet the definition. But as a physician, one can argue their respiratory system was failing. Should you wait and let them become hypoxic and THEN intubate them for the sake of reimbursement? Of course not. There’s not much guidance on these situations. The coding guidelines default to “whatever the physician says it is…”

• If it’s not clear and you as a physician think it’s respiratory failure, then document it. Let the insurance / denials team fight that fight.

“What about the surgical patient that is extubated to high-flow nasal, bipap, etc?”

• If anesthesia / the surgery exacerbated an underlying lung disease, then this may be respiratory failure.

• However, “post-surgical respiratory failure” is one of the Patient-Safety indicators (PSI 11). Essentially, your surgeon and hospital may get dinged if they have a high rate of post-surgical respiratory failure. Keep this in mind. “Pulmonary insufficiency” may be appropriate in this situation, but that is a whole other topic.