Breathe Easy: Coding Respiratory Failure in the Inpatient Setting
by Pamela J. Haney, MS, RHIA, COC, CIC, CCS
Respiratory failure is a condition in which not enough oxygen passes from the lungs into the blood. The body’s organs, such as heart and brain, need oxygen-rich blood to work well. It can also occur if the lungs cannot properly remove carbon dioxide (a waste gas) from the blood. Too much carbon dioxide in the blood can harm the body’s organs. Both of these problems—a low oxygen level and a high carbon dioxide level in the blood—can occur at the same time. Acute respiratory failure can develop quickly and may require emergency treatment.
Signs and symptoms of respiratory failure may include shortness of breath, rapid breathing, and air hunger (feeling like you can not breathe in enough air). In severe cases, signs and symptoms may include a bluish color on the skin, lips, and fingernails; confusion; and sleepiness.
How is Chronic Respiratory Failure different?
Chronic respiratory failure is very common in patients with severe COPD and other chronic lung diseases such as cystic fibrosis and pulmonary fibrosis. It is characterized by a combination of hypoxemia, elevated pCO2, elevated bicarbonate level, and normal pH (7.35–7.45). The most important tip-off to chronic respiratory failure is chronic dependence on supplemental oxygen such as “home O2.”
What about Acute-on-chronic Respiratory Failure?
When a patient experiences an acute exacerbation or decompensation of chronic respiratory failure, he has “acute-on-chronic” respiratory failure. It is recognized by any of the following:
- Worsening respiratory symptoms
- Greater hypoxemia (hypoxemic)
- Elevated pCO2 with pH < 7.35 (hypercapneic)
During an acute exacerbation, acidic carbon dioxide (pCO2) may accumulate rapidly (“CO2 retention”), causing acidosis with a pH < 7.35 (acute hypercapneic respiratory failure). This would be acute-on-chronic respiratory failure. Worsening of symptoms requiring an increase in supplemental oxygen also indicates an “acute exacerbation” of chronic respiratory failure.
So How Do We Code Acute Respiratory Failure in ICD-10?
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 depending on the circumstances of the admission. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.
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.
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 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 may be applied in these situations.
Respiratory failure is a life-threatening situation that is caused by an underlying condition such as diseases of the circulatory system, respiratory system, central nervous system and respiratory muscles. The primary goal of the treatment of acute respiratory failure is to assess the severity of the underlying disease and to correct the oxygen deficiency. As with other conditions, if the documentation is not clear, query the provider.
References: Coding Clinic, Second Quarter 1990, page 20-21; ICD-10-CM Official Guidelines for Coding and Reporting, 2011.
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