Coding Guidelines for Respiratory Failure

on Tuesday, 07 February 2017.

It seems that in the world of coding, “respiratory failure” (whether acute, chronic or acute on chronic) continues to be a daily challenge. Very seldom is it a simple cut and dry diagnosis. There always seems to be just enough gray to give coders on any given day some doubt. It’s not only important for a coder to be familiar with the guidelines associated with respiratory failure but they should also be aware of the basic clinical indicators as well.

OFFICIAL CODING GUIDELINE Acute or acute on chronic respiratory failure may be reported as principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Refer to Section II of the ICD-10-CM Official Guidelines for Coding and Reporting on “Selection of Principal Diagnosis”.

 

Please note: Coding must be based on provider documentation. Establishing a patient’s diagnosis is the sole responsibility of the provider. Coders should not disregard physician documentation and/or their clinical judgement of a diagnosis, based on clinical criteria published by Coding Clinic or any other source. Sources such as Coding Clinic should be used to become familiar with clinical criteria for a condition to guide coders in reporting the most accurate and specified diagnosis/procedure possible.   If for any reason there is doubt due to lack of clinical indicators/criteria, then that physician should be queried for clarification. Refer to Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinic 4th Qtr. 2016 page 147 for further clarity on this guideline.

Respiratory Failure

  1. Life-threatening condition that may be caused by a respiratory condition as well as a non-respiratory condition.
  2. Look for documented signs / symptoms of:
    • SOB (shortness of breath)
    • Delirium and/or anxiety
    • Syncope
    • Use of accessory muscles / poor air movement
    • Distended neck veins / peripheral edema
    • Tachycardia
    • Tachypnea
    • Confusion
    • Sleepiness
    • Altered consciousness
    • Cyanosis (bluish color to skin, lips and/or fingernails)
    • Pursed lips
    • Difficulty / inability speaking due to respiratory difficulty
    • Profuse sweating
    • Restlessness
  3. Acute Respiratory Failure is supported as principal diagnosis when at least 2 of the following critical values (ABG’s) are met.
    • pH < 7.35
    • PO2 < 55
    • PCO2 > 50
      Keep in mind, this is a guideline and not solely to be the determining factor for   diagnosing Acute Respiratory Failure. A patient with a chronic lung disease such as COPD may have an abnormal ABG level that could actually be considered that particular patient’s baseline. What is normal for one patient could be abnormal for another. In a patient with a chronic lung condition, the physician would consider the degree of change from a patient’s baseline before diagnosing Acute Respiratory Failure.
  4. Acute Respiratory Failure
    • Common causes:
      • Pneumonia
      • Cardiac arrest
      • Chest trauma
      • Overdose
      • Heart failure
      • Pulmonary embolism
      • COPD exacerbation
      • Asthma exacerbation
      • Inhalation of toxic chemicals, smoke or fumes
      • Stroke
      • Obstruction
    • Develops quickly
    • Short-term condition
    • Usually admitted to ICU
    • Requires aggressive and/or emergency treatment via oxygen through nasal cannula, face mask, ventilation and/or tracheostomy
    • Patient receiving 40% or more supplement O2 strong indication
    • Absence of vent does not preclude diagnosis
    • Requires close monitoring and evaluation
  5. Respiratory Acidosis (CC)
    • Is the same as Acute Hypercapnic Respiratory Failure
    • Respiratory Acidosis is a “CC” whereas Acute Hypercapnic Respiratory Failure is a “MCC”
    • Query for clarification when Respiratory Acidosis is documented
  6. Chronic Respiratory Failure
    • Common Causes:
      • COPD
      • Pulmonary fibrosis
      • Cystic fibrosis
      • Interstitial lung disease
      • Spinal cord injury
      • Muscular dystrophy
      • Chest injury
    • Develops gradually overtime
    • Ongoing condition that requires long-term treatment
    • Home O2 and/or trach status are indications of CRF
  7. Post-procedural Respiratory Failure
    • Code J95.821 is reported when respiratory failure follows surgery
    • Code J95.822 is reported when respiratory failure follows surgery and the patient has known/documented chronic respiratory failure

 Four classification types for ARF

  • Hypoxic – most common
    • Common acute symptoms:
      1. Tachycardia
      2. SOB
      3. Rapid breathing
      4. Confusion
      5. Inability to communicate
      6. Hypotension
  • Hypercapnia – often accompanied by hypoxemia
    • Common acute symptoms
      1. Dizziness
      2. Muscle weakness / twitching
      3. Elevated blood pressure
      4. Tachycardia
      5. Lethargy
      6. Headache
      7. Confusion
      8. Flushed skin
    • Post-operative
    • Shock – Septic, Cardiogenic or Hypovolemic

Treatment

  • Humidified oxygen therapy
  • Mechanical ventilation, BiPAP, CPAP
  • Bronchodilation
  • Establish electrolyte and pH balance
  • Treatment of the underlying source/cause

 

Acute Respiratory Failure as Principal Diagnosis

OFFICIAL CODING GUIDELINE
ICD-10-CM codes from subcategory J96.0 or subcategory J96.2

Official Guidelines for Coding and Reporting:

ICD-10-CM – Section I.C.10.b.1

Acute or Acute on Chronic Respiratory Failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

 

OFFICIAL CODING GUIDELINE
ICD-10-CM codes from subcategory J96.0 or subcategory J96.2

Official Guidelines for Coding and Reporting:

ICD-10-CM – Section I.C.10.b.3

When a patient is admitted with Respiratory Failure and another acute condition (e.g., Myocardial Infarction, Cerebrovascular Accident, Aspiration Pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the Respiratory Failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II.C) may be applied in these situations.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

 

When coding Respiratory Failure (or any condition) and trying to determine whether it should be assigned as principal diagnosis or not, look for:

  1. All signs and symptoms at the time of admission
  2. Clinical indicators
  3. Supporting physician documentation
  4. Treatment plans

With any record, keep in mind that because a condition may be present on admission does not necessarily mean it qualifies for principal diagnosis. You have to ask yourself these questions:

  • After study, is this the condition that was chiefly responsible for admission?
  • How aggressive was the work-up and treatment?
  • Is there another condition that equally meets the criteria for principal diagnosis?
  • Are there any chapter specific guidelines to consider?
  • Could this condition have been treated as an outpatient?

I wish I could say that assigning the appropriate principal diagnosis and coding in general was as easy as ABC, but it’s not. Some are a little easier than others but there seems to always be a little gray area to muddle through. Clear and precise documentation goes a long way in helping to determine the principal diagnosis.

As you take on a record to code, forget about the one you just finished. Each record and the circumstances surrounding the admission will be different.   Always be aware of the coding guidelines and follow through the steps listed above. You’ll find that assigning the principal diagnosis will be a little easier.

Article by Marsha Winslett

Marsha Winslett RHIT, CCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an Inpatient Coding Consultant at Medical Management Plus, Inc.  Marsha has over 28 years’ experience in the coding profession and has held various positions such as DRG coordinator, Coding Supervisor and HIM Supervisor. In her current position, Marsha reviews records and assists clients with coding accuracy, compliance, education and Case Mix Index (CMI) as they relate to specific entities concerning Medicare. You may contact Marsha at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

References:

ICD-10-CM/PCS Official Coding Guidelines for 2017

2017 CDI Pocket Guide

2016 CDI Pocket Guide

2017 AHA Coding Handbook

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