Pulmonology Coding Alert

Use unspecified codes when test results don’t reveal blood gas changes.

When your pulmonologist diagnoses acute exacerbation of chronic respiratory failure, choose from three code choices depending on the presence of hypercapnia or hypoxia from the results of blood gas analysis.

ICD-9: When your pulmonologist identifies acute exacerbation of chronic respiratory failure, you’ll report this with 518.84 (Acute and chronic respiratory failure). 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.

Reminder: If the respiratory failure has occurred due to trauma or surgery, you cannot use 518.84 to report the diagnosis. Instead, you will have to report this with 518.53. Also, you should use 518.84 only if the diagnosis is acute on chronic respiratory failure. If the patient only has acute respiratory failure, you’ll report this with 518.81 (Acute respiratory failure).

ICD-10: When you make the transition to ICD-10 codes, you’ll report a diagnosis of acute on chronic respiratory failure with J96.2 (Acute and Chronic respiratory failure). But, with ICD-10, you will need to further expand your reporting options based on whether the patient has type I or type II respiratory failure. You will need to look at the tests (arterial blood gases) performed to see if your pulmonologist has identified hypercapnia or hypoxia.

Based on the presence of hypoxia or hypercapnia, J96.2expands using a 5th digit expansion into the following three codes:

• J96.20 (Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia)
• J96.21 (Acute andchronic respiratory failure with hypoxia)
• J96.22 (Acute and chronic respiratory failure with hypercapnia)

 As in ICD-9, you cannot use these code sets if your clinician’s diagnosis is either acute or chronic respiratory failure. For these you will have to use J96.0- (Acute respiratory failure) and J96.1- (Chronic respiratory failure).

Focus on These Basics Briefly

Documentation spotlight: When your pulmonologist arrives at a diagnosis of acute exacerbation 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, and the presence of cyanosis. Additional testing may reveal pulmonary hypertension.Whenever your pulmonologist diagnoses acute on 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 a renal cause for the respiratory failure.

Tests: Your pulmonologist will diagnose acute and chronic respiratory failure beginning with history and signs and symptoms. Once he suspects acute exacerbation of 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 a chest x-ray (this again helps in identifying cause and nature offailure), and echocardiography to check if the respiratory failure has a cardiogenic cause.

Example: Your pulmonologist assesses a 69-year-old male patient for complaints of severe dyspnea and restlessness. The patient complains of incidents of dyspnea over the past few weeks that had aggravated to the present state. The patient presents with a history of emphysema and a history of smoking for the past 35 years.

During examination, the patient appears confused and in a state of anxiety. Your pulmonologist notes presence of cyanosis and tachycardia. Upon auscultation, he notes the presence of fine crackles. Since the patient is experiencing severe trouble breathing on his own, the patient is put on respiratory support.

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 PaCO2> 50 mm Hg and chest x-ray appears clear. The CBC results show the presence of polycythemia while other tests results were normal. 

Your pulmonologist arrives at a diagnosis of acute exacerbation of chronic respiratory failure.

What to report: You report the evaluation of the patient with 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…), and J96.22 if you are using ICD-10 codes or 518.84 if you are using ICD-9. You need to use J96.22 as PaCO2 values were higher than 50mm of Hg indicating hypercapnia.