We have been seeing a high volume of denials due to documentation that does not demonstrate medical necessity for admission for the diagnosis of COPD exacerbation.
The following helps support medical necessity when documenting on COPD exacerbation patients:
- 3 nebulizer treatments in the ER
- Pulse-ox less than 89%
- May be obtained on room air or supplemental oxygen if does not use home oxygen therapy (i.e. – does not have chronic respiratory failure).
- Must be obtained on their usual home oxygen requirements or higher supplementation if has chronic respiratory failure. Values obtained on room air alone not useful for justifying medical necessity in these patients since they already require oxygen supplementation at baseline.
- ABG with PaO2 <60 or PaCO2 > 50
- Respiratory distress as noted by accessory muscle usage and tachypnea
- Increased work of breathing as noted by fragmented sentences or hunched over posture
Download the complete tip, COPD Exacerbation: Documenting Medical Necessity.