Respiratory Failure &
Pneumonia Definitions
Workgroup
Purpose
• To develop standard clinical definitions on select
diagnoses & categories to be used consistently across
all hospitals in Maryland


Definitions will be informed by published criteria, existing hospitaldeveloped definitions and supported by industry consensus and
comments from the field
Definitions will not conflict with federal inpatient coding guidelines and
will be applied to any occurrence of the diagnosis, not only in scenarios
that might trigger a PPC
• Our goal is that these definitions will be considered and
adopted by hospitals’ Medical Executive Committees
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Background
• Under the state’s waiver agreement, hospitals must meet reduction
targets for Potentially Preventable Complications (PPCs)
 Additionally, the Health Services Cost Review Commission
(HSCRC) incorporates reduction targets into payment policy
• Having a uniform set of clinically defining criteria may facilitate care
improvement
 Consistency allows for both a performance comparison among
hospitals and for a measurement of an individual hospital’s
performance improvement over time
 Consistency helps demonstrate that Maryland hospitals have
put in time and effort to achieve clinically significant
performance improvement in addition to improvement achieved
through revised documentation practices
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Participants
HOSPITALS
Johns Hopkins
Lisa Grubb, Director of Quality Management, Johns Hopkins Bayview
David Pearse, MD, Medical Director, Johns Hopkins Bayview
Carol Ware, QI Team Leader for Special Projects, Johns Hopkins Hospital
LifeBridge Health
Jaime Barnes, MD, Medical Director, Critical Care Medicine, Northwest Hospital
Carol McNutt, Manager & Clinical Documentation Specialist, Sinai Hospital and Northwest Hospital
MedStar Health
Deborah Cline, Clinical Documentation Specialist, Medstar Franklin Square Medical Center
University Of Maryland
Jason Birnbaum, MD, Chair, Medicine Department & ICU Director, UM Upper Chesapeake & Harford Memorial
Tina Simmons, Quality Manager, UM Upper Chesapeake Medical Center
Peninsula Regional Medical Center
Robert Chasse, MD, Critical Care Medical Director, Peninsula
Susan Elerding, Medical Staff Clinical Quality Coordinator, Peninsula
Lisa Gray, Clinical Documentation Specialist, Peninsula
Gwyndle Kravec, Executive Director Health Information Management, Privacy Officer, Peninsula
Charles Silvia, MD, Vice President of Medical Affairs & Chief Medical Officer, Peninsula
Christopher Snyder, Chief Medical Information & Quality Officer, Peninsula
Michelle A. Taylor, Business Intelligence & Clinical Analytics, Peninsula
STAFF
Maryland Hospital Association
Nicole Stallings, Vice President
Justin Ziombra RN, Analyst
Berkeley Research Group
Joni Dion, Associate Director
Kristen Geissler, Managing Director
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Phase 1 Meeting Calendar
UTI
PPCs 65, 66
Delayed
Renal
PPCs 24, 25
February 23
OB
PPCs 55, 56, 57, 58
March 5
Respiratory
PPCs 3, 4, 5, 6
February 19
March 10
All meetings to be held from 8:30 – 11:30 at MHA
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Meeting Workflow Schedule
•
•
•
Meeting 2, February 19:
 Review feedback from stakeholders and update draft definitions
Homework prior to Meeting 3:
 Draft definitions will be submitted to hospital field for comment
Meeting 3, March 10:
 Review comments
 Finalize definitions
6
Key Takeaways From First Meeting
and Workgroup Feedback
1 of 2
Respiratory Failure
•
The group decided that relying principally on lab results and pulse oximetry to define
respiratory failure is problematic for four reasons:

1) Many patients are not receiving routine ABGs

2) Some patients, particularly those in post-operative recovery, may have an
abnormal ABG, however the result often normalizes in a short period of time and is
not necessarily indicative of respiratory failure

3) Some patients with chronic respiratory conditions have baseline ABGs that are
abnormal

4) Defining respiratory failure principally through ABG results is more appropriate as a
retrospective screen for chart reviews and studies. A more comprehensive definition
of respiratory failure would provide clinicians with a useful prospective tool
•
The workgroup concluded that the defining criteria for respiratory failure may include lab
values and other signs, but should also incorporate the severity of intervention required
•
The workgroup concluded that respiratory failure occurs when a patient has a need for
either a mechanical ventilator or a moderate support intervention (such as BiPAP, CPAP, or
High Flow Therapy) for ventilation and gas exchange

This criteria excludes post-surgical patients
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2 of 2
Respiratory Failure
•
Patients requiring a milder intervention, such as oxygen delivered through a nasal
cannula when physiologically required, might still be in respiratory failure, however
other criteria should be considered
•
These criteria include:

1) The patient’s baseline respiratory function: The interventions detailed above
are less indicative of respiratory failure in a patient who is on oxygen therapy at
home and has a history of lung disease

2) The length of time the intervention is required: The longer oxygen therapy is
required, the more indicative this intervention is of respiratory failure (length of
time was left undefined by the workgroup)

3) Associated signs and symptoms: Tachypnea, labored breathing, cyanosis,
and hypertension or hypotension are symptomatic of respiratory failure

4) Escalation: An increasing requirement for oxygen (i.e., higher FiO2) or the
need for higher ventilation support (e.g. CPAP to Vent) is symptomatic of
respiratory failure
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Post-Operative Respiratory
Insufficiency
• A patient ventilated in the normal post-operative period does not, in
of itself, constitute a diagnosis of respiratory failure or insufficiency
 It is not uncommon that patients require ventilation as part of the
normal course of recovery during the 48 hours following surgery
• For coding purposes, the intubation is not coded as respiratory
failure if this is an expected outcome taking place under 48 hours
post-surgery
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Pneumonia
•
The workgroup decided to use a more comprehensive definition for pneumonia than
the criteria crafted by the CDC as many patients with pneumonia have a negative
chest x-ray that is not necessarily followed with a CT scan
•
The definition for pneumonia is as follows:
Patient must have two of the following:
Signs
A Temperature > 38 or < 36
Or
Leukopenia (<4000 WBC/mm3) or Leukocytosis (>12,000 WBC/mm3)
Symptoms
Purulent Sputum
Or
Cough, Dyspnea or Tachypnea
Imaging
A positive Chest X-Ray or CT
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Aspiration Pneumonia
•
The workgroup decided to define aspiration pneumonia as a case of
pneumonia (as defined in the ‘pneumonia’ criteria in the previous slide) in
which the signs and symptoms last longer than 48 hours and in which
aspiration was the likely cause, as determined by the provider
•
Instances where the patient likely aspirated and displays signs and
symptoms of pneumonia that resolve in 48 hours or less should be
considered aspiration pneumonitis instead
•
The code for this event would be for pneumonitis, which also would count
as a Potentially Preventable Complication (PPC)
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Respiratory Failure Feedback
• The workgroup should consider enumerating how obstructive sleep
apnea and the use of CPAP at home fit into the first criteria (i.e., the
patient’s baseline function)
• The length of time may not necessarily be indicative of respiratory
failure, some patients are diagnosed after only brief durations of
interventions
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Post-Operative Respiratory
Insufficiency Feedback
• There were some concerns that our definition might confuse
the issue in instances where patients are likely to be on a vent
longer than 48 hours after surgery
• During the first meeting, we concluded that there weren’t any
types of cases where patients are routinely expected to
remain on a vent longer than 48 hours
 Is this something we want to revisit?
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Workgroup Discussion
• How should our initial consensus on the defining criteria
for respiratory failure, post-operative respiratory
insufficiency, pneumonia and aspiration pneumonia be
changed?
 How can we make the definition for respiratory
failure more objective?
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Homework
• We will disseminate the consensus criteria for
Respiratory Failure and Pneumonia that we develop
here today to all hospitals
• We will distribute their comments to you prior to our next
meeting
• Please consider these comments and come prepared to
finalize criteria at our next meeting
• Our next meeting is here, on March 10th, at 830am
Thank You!!
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Appendix – Respiratory Failure and
Pneumonia Codes
Respiratory Failure ICD-9-CM Codes
Acute Pulmonary Edema and Respiratory
Failure
ICD-9-CM Code
Acute respiratory failure
518.81
Other pulmonary insufficiency, not elsewhere
classified following trauma and surgery
518.52
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Related ICD-9-CM Codes
Other Respiratory Diagnoses
ICD-9-CM Code
Respiratory insufficiency (Dyspnea &
respiratory abnormality)
786.09
Acute respiratory insufficiency (Other
pulmonary insufficiency)
518.82
Hypercapnia (Dyspnea & respiratory
abnormality)
786.09
Hypoxemia
799.02
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Respiratory Failure ICD-10-CM Codes
Respiratory Failure
Acute respiratory failure (includes respiratory
failure, not otherwise specified)
ICD-10 Will Require Greater Specificity To
Accurately Capture The Condition
ICD-9-CM Code
518.81
ICD-10-CM Code
Acute respiratory failure, unspecified whether
with hypoxia or hypercapnia
J9600
Acute respiratory failure with hypoxia
J9601
Acute respiratory failure with hypercapnia
J9602
Respiratory failure, unspecified, unspecified
whether with hypoxia or hypercapnia
J9690
Respiratory failure, unspecified with hypoxia
J9691
Respiratory failure, unspecified with
hypercapnia
J9692
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Pulmonary Insufficiency
ICD-10-CM Codes
Pulmonary Insufficiency
Other pulmonary insufficiency, not elsewhere
classified following trauma and surgery
ICD-10 Will Require Greater Specificity To
Accurately Capture The Condition
ICD-9-CM Code
518.52
ICD-10-CM Code
Acute pulmonary insufficiency following thoracic J951
surgery
Acute pulmonary insufficiency following
nonthoracic surgery
J952
Other chronic pulmonary insufficiency following
surgery
J953
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