When you learn about medical coding, you must know when to use it and how to use it! Often during an
emergency or acute care healthcare setting, we find patients with a diagnosis of “Respiratory
Failure”. Respiratory coding is an important coding aspect where the clinical coding and clinical
documentation improvement (CDI) professionals need to have a strong knowledge and understanding of
medical/clinical aspects of diseases as well as the coding guidelines and rules.
Most of the healthcare professionals lack in understanding the need for respiratory coding. They
frequently get confused while coding for respiratory failure. This article provides an interesting
brief discussion on the clinical aspects and
ICD-10-CM coding of Respiratory
Failure.
Clinical Overview of Respiratory Failure:
It’s essential to review some of the most important clinical aspects and indicators that help
understand the respiratory system and the condition of “Respiratory Failure.”
While we breathe, we partake in four steps, they are:
Ventilation from the ambient air into the alveoli of the lung.
Pulmonary gas exchange from the alveoli into the pulmonary capillaries.
Gas transport from the pulmonary capillaries through the circulation to the peripheral capillaries
in the organs.
Peripheral gas exchange from the tissue capillaries into the cells and mitochondria.
The lungs act as the primary organs for the respiratory system.
When we hear the diagnosis or term “respiratory failure” we know that it’s serious and has the
potential to be life-threatening. It can be caused by respiratory conditions like COPD, Pneumonia,
Cystic Fibrosis or non-respiratory conditions like Trauma, Burns, Drug or Alcohol Overdose.
Acute respiratory failure comes suddenly over hours or within a day or two from impaired
oxygenation, impaired ventilation, or both. It’s important to review the documentation to see if the
RR (respiratory rate) is less than 20 or greater than 10, if there is any wheezing, and/or nasal
flaring; accessory muscle use for breathing, etc., as these are signs that can indicate acute
respiratory failure.
Chronic respiratory failure often develops slowly and goes on for months and years since the airways
that carry air to the lungs are narrowed and damaged. A patient with COPD that has progressed to the
end-stage often utilizes portable oxygen daily. The most common cause of COPD is smoking.
Acute and Chronic respiratory failure include both extremes of the failure.
Respiratory failure can occur if the lungs can’t properly remove carbon dioxide from the blood. Too
much of carbon dioxide can spoil the lungs.
One of the crucial goals of treating respiratory failure is to get oxygen to the lungs and other
organs and remove carbon dioxide from the body. Another goal is to treat the underlying cause of the
condition.
Overview of ICD-10 in Respiratory Coding:
The golden rule to be learnt for respiratory coding is to have the diagnostic documentation by the
provider in order to assign the ICD-10-CM codes and follow official guidelines and instructions.
The guidance and instructions published by the American Medical Association’s respiratory coding
clinic must be adhered to ICD-10-CM Chapter 10 Diseases of the Respiratory System J00-J99. This is
where one can locate the specific guidelines relating to the coding of respiratory failure and all
should be reviewed and followed.
When a respiratory condition is described as occurring in more than one site and is not specifically
indexed, it should be classified to the lower anatomic site.
For example, tracheobronchitis to bronchitis in J40. For respiratory coding, following conditions
from Chapter 10 apply to all codes in the range of J00-J99.
Use additional code, where applicable, to identify:
Exposure to environmental tobacco smoke(Z77.22)
Exposure to tobacco smoke in the prenatal period (P96.81)
History of tobacco use (Z87.891)
Occupational exposure to environmental tobacco smoke(Z57.31)
Tobacco dependence (F17.0-)
Tobacco use(Z472.0)
In ICD-10-CM the classification of Respiratory Failure (J96) includes “acute (J96.0-)”, “chronic”
(J96.1-).
“Acute and chronic” (J96.2-), and “unspecified” (96.9-), each with hypoxia or hypercapnia or
unspecified at the fifth character of the code.
There are certain guidelines regarding the assignment of “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 established to be chiefly
responsible for the admission to the hospital. The selection should be supported by the Alphabetic
Index and Tabular List.
Moreover, chapter-specific coding guidelines such as obstetrics, poisoning, HIV, newborn that
provide sequencing direction take precedence.
Acute care inpatient hospital MS-DRGs: Principal diagnosis code 00-J96.92 respiratory failure
without a procedure, will group to any of the following three MS-DRGs.
189 Pulmonary edema and respiratory failure
928 Full thickness burn with skin graft or inhalation injury with cc/mc
929 Full thickness burn with skin graft or inhalation injury without cc/mc
Under Medicare Risk Adjustment (RA), a diagnosis of Respiratory Failure with any of the codes J96.00
to J96.92 will currently result in a hierarchical condition category or HCC.
Sometimes when the healthcare professional is questioned regarding the documentation, they must
follow AHIMA/ACDIS Practice Brief regarding “Guidelines for Achieving a Compliant Query” and the
AHIMA “Standards of Ethical Coding.”
Points to remember in respiratory coding:
Acute and Chronic Conditions: If the same condition is described as both acute (sub-acute) and
chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code
both and sequence the acute (sub-acute) code first.
There are a total of twelve ICD-10-CM codes for the classification of Respiratory Failure.
The alphabetic index and the tabular list must also support the code selection.
Chapter specific rules in the Respiratory System are found in Chapter 10.
Assign additional code(s) where applicable to identify exposure to environmental tobacco smoke or
exposure to tobacco smoke in the perinatal period, or history of smoking.
Not all conditions occurring during surgery, following surgery or medical care are complications and
thus the provider may need to be queried for clarification.
Respiratory coding involves acute concentration just like any other specialty coding. Any queries
related to coding are better understood by outsourcing companies. It’s best to approach them for
further billing operations.
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