Vol. 15 •Issue 11 • Page 10
Take a Deep Breath and Review the Revised Respiratory Failure Coding Guidelines
Prepared by HSS Inc. staff
The coding and sequencing of respiratory failure continues to present a challenge to the coding community. The First Quarter 2005 issue of Coding Clinic establishes some new guidelines for HIM coders to follow. Before applicants take the upcoming coding certification exams, they should ensure that they clearly understand the new guidelines and know what to look for in the medical record documentation. Although respiratory failure is not an uncommon diagnosis in the acute care setting, the underlying causes of it and the level of accurate documentation of it vary widely. This article will explore the new instructions.
The definition of acute respiratory failure is severe respiratory dysfunction resulting in abnormalities of oxygenation or CO2 elimination and impairing or threatening the function of vital organs. Respiratory failure can be a failure of oxygenation (the tissues of the lung are not functioning properly), a failure of ventilation (an impairment of airflow in and out of the lungs) or both. An example of a failure of oxygenation would be an acute exacerbation of bronchial asthma in a patient with lung tissue damage due to emphysema. An example of a failure of ventilation would be compression of the trachea blocking the airflow, caused by metastatic carcinoma of the thoracic lymph nodes. A patient with acute respiratory failure usually presents with increased work of breathing as typified by rapid respiratory rate, use of accessory muscles of respiration (such as intercostal muscle retraction) and possibly paradoxical breathing and/or cyanosis.
Respiratory failure is a life-threatening disorder that requires close patient monitoring and evaluation, with aggressive management usually requiring placement of the patient in a monitored bed, aggressive respiratory therapy and/or mechanical ventilation. However, the absence of mechanical ventilation does not preclude the diagnosis of respiratory failure. In many cases, respiratory failure is the final pathway of a disease process, or a combination of different processes, and can be a result of an abnormality in any of the components of the respiratory system, peripheral nervous system, central nervous system, respiratory muscles and chest wall muscles. In most cases the treatment is directed toward correction of the hypoxemia and stabilization of the ventilatory and hemodynamic status.
Respiratory failure, code 518.81, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (obstetrics, poisoning, HIV, sepsis, newborn) that provide sequencing direction take precedence. Respiratory failure may be listed as a secondary diagnosis if it occurs after admission. Again, the fact that the respiratory failure was managed without intubation and mechanical ventilation does not preclude the use of 518.81. If the diagnosis is otherwise supported by the contents of the medical record, then respiratory failure should be assigned as the principal diagnosis.
When a patient is admitted with respiratory failure and another acute condition (e.g., myocardial infarction, cerebrovascular accident), the principal diagnosis will not necessarily be the same for every admission. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are responsible for occasioning the admission to the hospital, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C) may be applied in these situations.
This new advice is very important to understand as it is different than that previously stated in guideline #1 and guideline #2, previously published in Coding Clinic, Second Quarter 1991, p. 3. It is, however, consistent with advice previously published in Coding Clinic, November-December 1987; Second Quarter 1990, pp. 11-12; Third Quarter 1991, p. 14; First Quarter 1993, p. 25; Second Quarter 2000, p. 21; and First Quarter 2003, p. 15.
To summarize the revised instructions, if acute respiratory failure and another acute condition both equally meet the definition of principal diagnosis, that is, both are responsible for occasioning the admission to the hospital, the instruction under Section II, C of the Coding Clinic Official Coding Guidelines may be followed:
“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 guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.”
But before automatically sequencing respiratory failure as principal diagnosis on all cases in which it’s present on admission, keep in mind that there are chapter-specific guidelines specifying that some codes have sequencing priority over codes from other chapters. For example:
• HIV/AIDS: For a patient with HIV or AIDS and respiratory failure, the HIV code is sequenced first because there is a chapter-specific guideline (Section I, C, 1, a, 2, a) that provides sequencing directions specifying that if a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions.
• Poisoning (Chapter 17): The poisoning codes are sequenced first because there is a specific guideline (Section I, C, 17, e, 2, d) specifying that the poisoning code is sequenced first, followed by a code for the manifestation.
• Sepsis: In the instance of sepsis with respiratory failure, the sepsis is sequenced first because there is an instructional note under subcategory 995.92 indicating to code first the underlying systemic infection. In addition, code 995.92 has a “use additional code” note to specify organ dysfunction and lists acute respiratory failure (518.81). As a result, respiratory failure would be sequenced as a secondary diagnosis.
• Obstetrical: Chapter 11 codes have sequencing priority over codes from other chapters (see ICD-9-CM Coding Guidelines Section I, C, 11, a, 1). So a patient who is pregnant or has recently delivered and presents with respiratory failure (e.g., due to a pulmonary embolism) would have the pregnancy related code, such as 673.2X (Obstetrical blood-clot embolism) sequenced as the principal diagnosis. The respiratory failure would be sequenced as a secondary condition.
• Newborn: Coding guidelines for Chapter 15 indicate that conditions having their origin in the perinatal period should be assigned codes from this chapter, regardless of whether death or morbidity occurs later. For coding and reporting purposes the perinatal period is defined as birth through the 28th day following birth. If a newborn patient has respiratory failure during the perinatal period, code 770.84 (Respiratory failure of newborn) would be assigned instead of the 518.81 code.
Coders should make every effort to become familiar with each type of respiratory failure listed above to ensure full compliance with the new guideline. Although some may see the revisions as increasingly confusing, they actually allow the coder to select the diagnosis that most contributed to the decision to admit the patient. In the past, there have been many instances in which this was not possible due to the sequencing guidelines in place. As always, it is essential to ensure that the medical staff understands the definition of principal diagnosis so that the medical record documentation is not overly confusing, inconsistent or ambiguous.
After review of the revised guidelines in the Coding Clinic, test your knowledge with the quiz below.
1. A 56-year-old patient with chronic myasthenia gravis is taken to the emergency department (ED). The physician documents that the patient is having an acute exacerbation of her disease and has developed acute respiratory failure. The patient is admitted due to the respiratory failure. How should the diagnosis codes be sequenced?
a. 518.81, 358.01
b. 358.00, 518.81
c. 358.01, 518.81
d. 518.81, 358.1
2. A patient is admitted through the ED with pneumonia and acute respiratory failure. How should the diagnosis codes be sequenced?
a. 518.81, 486
b. 515, 518.81
c. 486, 518.81
d. 518.81, 515
3. A 67-year-old patient with underlying chronic congestive heart failure arrived in the hospital in acute respiratory failure. He was intubated and admitted to the hospital. The physician documents acute respiratory failure as the reason for admission. How should the diagnosis codes be sequenced?
a. 428.0, 518.81
b. 799.1, 428.0
c. 518.81, 428.0
d. 518.81, 428.0, 799.1
4. A 29-year-old postpartum patient is admitted to the hospital after she developed a pulmonary embolism leading to respiratory failure. How should the diagnosis codes be sequenced?
a. 673.24, 518.81
b. 518.81, 673.24
c. 673.84, 518.81
d. 770.84, 518.81
5. A 17-year-old patient was brought to the ED and diagnosed as overdosing on crack. She was admitted to the hospital with respiratory failure. How should the diagnosis codes be sequenced?
a. 518.81, 970.8, 305.60
b. 305.60, 518.81, 970.8
c. 970.8, 518.81, 305.61
d. 970.8, 518.81, 305.60
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the AHA.
CPT is a registered trademark of the AMA.
ANSWERS to CCS PREP!:
1. a. 518.81, 358.01
Acute respiratory failure (518.81) may be designated as principal diagnosis if it led to the hospital admission, or it may be listed as an associated condition if it occurs after admission. The myasthenia gravis was specified as in acute exacerbation so code 358.01 is most appropriate. See Coding Clinic, 4th Qtr. 2004, p. 139 for this guideline.
2. a. 518.81, 486
If the reason for admission is respiratory failure and pneumonia, the respiratory failure should be sequenced first. These conditions are not co-equal. Clinically, the pneumonia led to the respiratory failure, which resulted in the patient being admitted. If respiratory failure develops after admission, the pneumonia would be sequenced first, and respiratory failure sequenced second. See Coding Clinic, 2nd Qtr. 2003, pp. 21-22 for this guideline.
3. c. 518.81, 428.0
In this example, the physician documented the acute respiratory failure as the reason for admission. Therefore 518.81 should be the principal diagnosis. Selection of the principal diagnosis is governed by the circumstances of admission. If the documentation is unclear regarding whether the congestive heart failure or the acute respiratory failure was the reason for admission, coders should query the physician. Also, code 799.1 (Respiratory arrest) contains an EXCLUDES note for designated respiratory failure and would not be an appropriate code for the case.
4. a. 673.24, 518.81
For this case, the obstetrical code is sequenced first because there is a chapter specific guideline (Section I, C, 11, a, 1) specifying that Chapter 11 codes have sequencing priority over codes from other chapters. Code 673.84 is not as specific as 673.24 and should not be assigned for this case. Likewise, code 770.84 is a newborn code and should not be assigned for this case.
5. d. 970.8, 518.81, 305.60
In this example, poisoning is sequenced first because there is a chapter-specific guideline (Section I, C, 17, e, 2, d) specifying that the poisoning code is sequenced first, followed by a code for the manifestation. The acute respiratory failure is a manifestation of the poisoning. See Coding Clinic, 1st Quarter 2005, p. 6 and First Quarter 1993, p. 25 for this guideline. Also, the drug abuse was not specified as a continuous habit, so code 305.61 is inappropriate.