How Do You Sequence ICD-10-CM Codes for Acute Respiratory Failure and Another Acute Respiratory Condition?

This blog post is intended to aid with principal diagnosis selection when a patient is admitted to inpatient status with acute respiratory failure and another acute pulmonary condition. Often a patient presents with acute respiratory failure and asthma, COPD exacerbation or pneumonia and is treated with intravenous antibiotics and/or steroids and oxygen. Treatment for these conditions often overlaps making it difficult to determine which condition should be reported as the principal diagnosis.

ICD-10-CM Coding Guidelines for Selection of Principal Diagnosis

The ICD-10-CM Official Guidelines for Coding and Reporting define the principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

Guideline II.B also states, “When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”

Despite the direction in the guidelines, coding professionals are often left in a quandary as to which condition to select as principal diagnosis when a patient is admitted with acute respiratory failure and another acute respiratory condition.

Being able to recognize the presence and treatment of acute respiratory failure is essential to determining if it is the condition that should be sequenced as the principal diagnosis.

What is Acute Respiratory Failure?

Definition of acute respiratory failure:

• Acute respiratory failure is when your lungs cannot release enough oxygen into your blood (hypoxic), which prevents your organs from properly functioning. It also occurs if your lungs cannot remove carbon dioxide from your blood (hypercapnic). Patients may even suffer from a combination of hypoxic and hypercapnic respiratory failure. This condition occurs rapidly; thus, it is referred to as acute respiratory failure.

Symptoms of acute respiratory failure:

• Dyspnea
• Elevated respiratory rate (> 20) or reduced respiratory rate (< 10)
• Shortness of breath
• Wheezing
• Labored breathing
• Accessory muscle use
• Retractions
• Cyanosis
• Nasal flaring
• Apnea or cessation of breathing

Clinical values indicating acute respiratory failure (Not valid for patients with acute on chronic respiratory failure):

• Acute hypoxic respiratory failure
  • PaO2 < 60 mmHg on room air measured by ABG, or
  • SpO2 < 91% on room air measured by pulse oximetry, or
  • P/F ratio < 300 on oxygen (to calculate please see P/F ratio calculator)
• Acute hypercapnic respiratory failure
  • PaCO2 > 50 mmHg with pH < 7.35 (ABG)
  • pCO2 > 55 mmHg with pH < 7.33 (VBG)

Although ABGs are the standard for diagnosing acute respiratory failure, acquiring arterial blood gas (ABG) values is not mandatory for making this diagnosis. If a patient has a SpO2 of less than 91% on room air or other clinical indicators of respiratory failure and has signs of respiratory distress, this qualifies as acute respiratory failure.

How is Acute Respiratory Failure Treated?

Treatments for acute respiratory failure include:

• Supplemental oxygen
• Steroids (inhaled/IV)
• Inhaled bronchodilators
• Mucolytics
• Bipap
• Mechanical ventilation

ICD-10-CM Coding Guidelines for Acute Respiratory Failure

Now that we’ve covered how to recognize the presence and treatment of acute respiratory failure, the next step to making correct principal diagnosis selection is familiarity with the relevant coding guidelines for this condition. Note that these guidelines provide direction specific to sequencing acute respiratory failure as the principal diagnosis or a secondary diagnosis and how to sequence acute respiratory failure and another acute condition.

I.C.10.b Acute Respiratory Failure

1) Acute respiratory failure as principal diagnosis

A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and 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.

2) Acute respiratory failure as secondary diagnosis

Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

3) Sequencing of acute respiratory failure and another acute condition

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 nonrespiratory 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.

II.C Two or more diagnoses that equally meet the definition for principal diagnosis

“In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.”

If 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.

Case Studies

Use the following case studies to analyze how pertinent clinical indicators and coding guidelines are applied in evaluating real world documentation.

Case 1: Patient was admitted with moderate persistent asthma with acute hypoxemic respiratory failure due to severe status asthmaticus. Based on the documentation the principal diagnosis could be either acute hypoxic respiratory failure or moderate persistent asthma with status asthmaticus. Both conditions were present on admission and equally treated. The use of acute hypoxic respiratory failure as PDX results in the more resource intensive DRG of 189.

Chart Documentation:

ED: “in acute distress. RR 37; pulse 151; tachypnea, accessory muscle usage, prolonged expiration, respiratory distress, nasal flaring and retractions. Decreased air movement, wheezing present. Initial oxygen saturation 82%, placed on NRB mask. Is unable to speak and is grunting, noted to be in tripod position. Duonebs started, IV ordered along with solumedrol and magnesium. Oxygen 8 l/min via aerosol mask.”

PN HD1: “12 yo male with moderate persistent asthma admitted with acute hypoxemic respiratory failure due to severe status asthmaticus. This morning was in moderate distress with RR in the 30s with I:E of 1:2 with moderate IC retractions…Oxygen via HHFNC @ 20 L/min.”

PN HD2: “Day 2 in the PICU for this 12 yo with moderate persistent asthma admitted with acute hypoxemic respiratory failure due to severe status asthmaticus likely related to a viral resp infection. Oxygen continues by aerosol Mask at 10 l/min”

DS: “Problems: Status Asthmaticus. Active Problems: Acute respiratory failure with hypoxia.”

Case 2: Patient was admitted with pneumonia and acute hypoxic respiratory failure. Based on the documentation the principal diagnosis could be either pneumonia or acute hypoxic respiratory failure since both conditions resulted in the admission and were equally treated. The use of pneumonia as PDX results in the more resource intensive DRG of 193.

Chart Documentation:

ED: “ED Course: Presents with fever, chest congestion, cough and hypoxia. In the ER patient is found to be diffusely wheezing, RR 24 and with hypoxia 86% SpO2 requiring 3 L oxygen. Chest x-ray shows congestion and possible infiltrates. Labs show WBC of 16.4 Diagnoses: 1. Acute respiratory failure with hypoxia presently on 3 L oxygen. 2. Pneumonia -IV antibiotics, sputum culture, nebulizer treatments.

DS: “Patient admitted with acute hypoxic respiratory failure and community acquired pneumonia with fever and elevated WBCs but no signs of sepsis. Patient was treated with oxygen at 3 liters, IV antibiotics and nebulizer treatment. Fever and hypoxia resolved, WBCs returned to normal and patient was discharged on room air to complete oral antibiotics at home.”

References

• ICD-10-CM Official Guidelines for Coding and Reporting – Principal Diagnosis and Acute Respiratory Failure
• Documentation tips: Acute respiratory failure - The Hospitalist
• Pinson & Tang CDI Pocket Guide: Respiratory Failure
• Pinson & Tang P/F ratio calculation
• AHA Coding Clinic for ICD-10-CM/PCS Smoke Inhalation and Acute Respiratory Failure, Fourth Quarter 2013 p. 121

Health Information Associates offers medical coding services, medical auditing services, and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities in the United States.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.