Respiratory Coding in FY2020

Written By Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer

Post by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10- CM/PCS Trainer.

Often in emergency and acute care healthcare settings we find patients with a diagnosis of “Respiratory Failure.” Clinical coding and clinical documentation improvement (CDI) professionals need to have a strong knowledge and understanding of both medical/clinical aspects of diseases as well as the coding guidelines and rules. This blog includes a brief discussion of the clinical aspects and ICD-10-CM coding of Respiratory Failure.

CLINICAL OVERVIEW: Let’s review some of the many clinical aspects and indicators that help understand the respiratory system and the condition of “Respiratory Failure.” As we breath (respiration) we partake in four steps:

  1. Ventilation from the ambient air into the alveoli of the lung.

  2. Pulmonary gas exchange from the alveoli into the pulmonary capillaries.

  3. Gas transport from the pulmonary capillaries through the circulation to the peripheral capillaries in the organs.

  4. Peripheral gas exchange from the tissue capillaries into the cells and mitochondria.

The lungs are the primary organ of the respiratory system. Humans have two lungs (right and left) with a total of 5 sections or lobes. The left lung has two lobes and the right lung has three. The rate of breathing and the volume of each breath are tightly regulated to maintain constant values of CO2 tension and pH of the blood.

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 a respiratory condition (i.e.., COPD, Pneumonia, Cystic Fibrosis) or non-respiratory condition (i.e., Trauma, Burns, Drug or Alcohol Overdose).

Acute respiratory failure comes on suddenly over hours or within a day or two from impaired oxygenation, impaired ventilation, or both. It’s important to review the documentation and check to see if the RR (respiratory rate) is less than 20 or greater than 10, fs there is any wheezing, and/or nasal flaring, accessory muscle use for breathing, etc., as these are signs that can indicate acute respiratory failure is present.

Chronic respiratory failure often develops slowly and is ongoing (months and years) due to 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 includes both severities of the failure.

Respiratory failure can occur if the lungs can't properly remove carbon dioxide (a waste gas) from the blood. Too much carbon dioxide in the blood can harm the body's organs. One of the main goals of treating respiratory failure is to get oxygen to your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat the underlying cause of the condition.

ICD-10-CM OVERVIEW: The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) AND follow Official Guidelines, which can be located at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2020-Coding-Guidelines.pdf

Guidance and direction published in the American Hospital Association ICD-10-CM/PCS Coding Clinic should also be adhered to. ICD-10-CM Chapter 10 Diseases of the Respiratory System (J00-J99), is where you can locate the specific guidelines relating to the coding of Respiratory Failure; all should be reviewed and followed. NOTE: 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 e.g. tracheobronchitis to bronchitis in J40. For coding conditions from Chapter 10 the following applies 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 specific 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 the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, 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 J96.00-J96.92 Respiratory Failure (without a procedure), will group to any of the following three MS-DRGs (ver. 37.0):

  • 189 Pulmonary edema and respiratory failure

  • 928 Full thickness burn with skin graft or inhalation injury with cc/mcc

  • 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.

There are times when the provider will need to be queried regarding their documentation, and we must follow the AHIMA/ACDIS Practice Brief regarding “Guidelines for Achieving a Compliant Query” and the AHIMA “Standards of Ethical Coding.”

REMEMBER:

  • Acute and Chronic Conditions: If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) 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 an 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.

References:

Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer

Gloryanne has been a HIM Coding professional and leader for over 40 years, specializing in clinical coding, compliance, ethics and CDI. She has been a National Director of Coding Quality and Education, for a large integrated healthcare delivery system and a Corporate Coding Compliance Senior Director for over 40 acute care hospitals, plus SNFs, Acute Rehab and Ambulatory Surgery Centers. Ms. Bryant was also a key national leader and advocate for ICD-10 Coding Education and Training from 2010 to mid-2016.

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