Pulmonology Coding Alert

Use separate code choices for acute exacerbation of chronic respiratory failure

When your pulmonologist arrives at a diagnosis of chronic respiratory failure, don’t forget to look at lab test results, especially arterial blood gas analysis as this holds the clue to identify the right ICD-10 code that you will report.

ICD-9: When your pulmonologist diagnoses chronic respiratory failure, you will have to report it with 518.83. If the respiratory failure is identified to be caused by an infectious organism, you will have to additionally code the causative organism using another ICD-9 code.

Caveat: You cannot use 518.83 to report a diagnosis of chronic respiratory failure if it the patient is suffering from acute exacerbation of the chronic respiratory failure. In such a condition, you will have to use the ICD-9 code 518.84 (Acute and chronic respiratory failure) to report the diagnosis.

ICD-10: When you switch over to using ICD-10 codes, you’ll report a diagnosis of chronic respiratory failure with J96.1 (Chronic respiratory failure). But, when using ICD-10 to report a diagnosis of chronic respiratory failure, you have to delve deeper into the patient documentation to check if your pulmonologist has withdrawn an arterial blood gas sample and sent it to the lab for analysis. Check the results of the ABG analysis to see if the patient has hypoxia or hypercapnia.

Based on the presence of hypoxia or hypercapnia, J96.1 expands using a 5th digit expansion into the following three codes:

• J96.10 (Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia)
  
• J96.11 (Chronic respiratory failure with hypoxia)
  
• J96.12 (Chronic respiratory failure with hypercapnia)
  

As in ICD-9, you cannot use J96.- if your clinician is identifying the condition as an acute exacerbation of chronic respiratory failure. In such a case, you will have to report the condition with J96.2- (Acute and chronic respiratory failure). J96.2 also expands into three codes in a similar manner as J96.1 based on the presence of hypoxia or hypercapnia.

Brush up on These Basics Briefly

Documentation spotlight: When your pulmonologist arrives at a diagnosis of chronic respiratory failure, some of the signs and symptoms that you are more likely to find in the patient documentation will include dyspnea, anxiety, restlessness, loss of consciousness, confused state and presence of seizures.

Upon examination, your pulmonologist might note the presence of crackles during auscultation, tachycardia, pulmonary hypertension and the presence of cyanosis. Whenever your pulmonologist diagnoses chronic respiratory failure, he will try to identify the cause for the condition. For example, a pulmonary cause for failure will include pneumonia, asthma or COPD. Alternately, your pulmonologist might look for a cardiogenic or for a renal cause for the respiratory failure.

Tests: Your pulmonologist will diagnose chronic respiratory failure beginning with history and signs and symptoms. Once he suspects chronic respiratory failure, he will withdraw an arterial blood sample and send it to the laboratory to check for arterial blood gases to record arterial oxygen tension (PaO2) and arterial carbon dioxide tension (PaCO2). Some of the other lab tests that will be performed will include a complete blood count to check for polycythemia, liver function tests and kidney function tests that will help identify the cause for the respiratory failure.

Apart from this, your pulmonologist will order for a chest x-ray (this again helps in identifying cause for failure), and echocardiography to check if the respiratory failure has a cardiogenic cause.

Your clinician might also opt to perform pulmonary function tests to check forced vital capacity, forced expiratory volume to help determine the diagnosis of the condition and to also know if the failure has pulmonary causes such as airway obstruction or any other lung conditions.

Example: Your pulmonologist reviews a 65-year-old male patient for complaints of increasing dyspnea and restlessness. The patient has been under your pulmonologist’s care for asthma for the past ten years. The patient complains that the symptoms that he has been experiencing have been there for sometime now and has been slowly increasing over the past few weeks and is not being relieved by use of the inhaler.

Your pulmonologist performs a comprehensive history taking and then proceeds to examine the patient. During examination, the patient appears confused and in a state of anxiety. Your pulmonologist notes presence of cyanosis, pulmonary hypertension and tachycardia.

Suspecting respiratory failure, your pulmonologist sends an arterial sample for analysis of blood gases. He also orders for a chest x-ray and echocardiography. He also asks for CBC, kidney and liver function tests.

The results of blood gas analysis return with a PaO2 < 60 mm Hg while PaCO2 values were normal and chest x-ray appears clear. The CBC results show the presence of polycythemia while other tests results were normal thus helping your clinician rule out renal causes for the condition.

Your pulmonologist arrives at a diagnosis of chronic respiratory failure based on the history, signs and symptoms, physical examination and from test results.

What to report: You report the evaluation of the patient with 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…), and J96.11 if you are using ICD-10 codes or 518.83 if you are using ICD-9. You need to use J96.11 as PaO2 values were lesser than 60mm of Hg indicating hypoxia.