ICD 10 Coding Alert

Know when a patient with a chronic condition needs an acute code reported.

Acute respiratory failure (ARF) is a medical emergency; reporting the condition with ICD-10-CM codes requires careful attention.

Use these tips to navigate the ICD-10-CM Official Guidelines and successfully report ARF claims.

Tip 1: Identify When ARF Is the Principal Diagnosis

“Acute respiratory failure is a short-term condition that usually happens unexpectedly and is a medical emergency. It is a decrease in the body’s ability to exchange oxygen and carbon dioxide between the lungs and circulation,” says Brandee Palmer COC, CPB, CPMA, CHONC, revenue cycle manager of Wichita State University Student Health Services and Pulmonary and Sleep Consultants of Kansas in Wichita, Kansas.

According to the ICD-10-CM Official Guidelines, section I.C.10.b.1, codes from J96.0- (Acute respiratory failure) or 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.”

This means that if the provider determines the patient is admitted to the hospital due to acute respiratory failure or an acute exacerbation of their chronic respiratory failure, then you’ll assign the appropriate code.

Scenario: Patient presents to the emergency department (ED) with rapid breathing, shortness of breath (SOB), and confusion. The provider measures the patient’s oxygen saturation, which is 85 percent, and the provider initiates oxygen administration. The patient has a history of chronic obstructive pulmonary disease (COPD). Following an examination, the provider determines the patient is in acute respiratory failure.

In this scenario, the acute respiratory failure is the principal diagnosis. You’ll assign one of the following codes:

• J96.00 (Acute respiratory failure, unspecified whether with hypoxia or hypercapnia)
• J96.01 (Acute respiratory failure with hypoxia)
• J96.02 (Acute respiratory failure with hypercapnia)

On the other hand, it is possible that a patient who is diagnosed with chronic respiratory failure suffers from an acute exacerbation of the chronic respiratory failure. In that instance, you’d assign one of the following diagnosis codes:

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

“Chronic respiratory failure progresses slowly and typically needs long-term care. It is an ongoing medical condition. The condition occurs when the airways to your lungs become damaged or narrow, which reduces the body’s ability to move air through the body,” Palmer adds.

Tip 2: Beware Other Causes of ARF

If the provider determines that the ARF is because of another condition, then you’ll report the ARF as a secondary diagnosis. According to the ICD-10-CM Official Guidelines, section I.C.10.b.2, “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.”

Scenario: A patient presents to the ED with acute onset of chest pain and SOB after some light exercise at home. The patient is sweating and anxious. The respiratory rate is 27 and O2 saturation is 88 percent. After starting supplemental oxygen, the O2 saturation increased to 97 percent. A chest computed tomography angiography (CTA) is ordered, which shows a bilateral central pulmonary embolism with a right to left ventricular. The provider diagnoses the patient with ARF caused by a bilateral central pulmonary embolism.

In this scenario, the bilateral central pulmonary embolism is the principal diagnosis and is causing the ARF in the patient. Following the ICD-10-CM Official Guidelines, you’ll assign I26.99 (Other pulmonary embolism without acute cor pulmonale) as the principal diagnosis. You’ll then assign an appropriate code from the J96.0- or J96.2- code subcategories.

Differentiate Hypoxia From Hypercapnia

Hypoxia and hypercapnia will also factor into your code selection. Hypoxia is a condition where the body tissues experience low levels of oxygen. Patients suffering from hypoxia may complain of headaches, confusion, anxiety, tachycardia (rapid heart rate), tachypnea (fast breathing), and breathing difficulties.

Hypercapnia, or hypercarbia, occurs when the patient experiences high carbon dioxide (CO2) levels in their blood. Symptoms of hypercapnia include, but are not limited to, SOB, headaches, fatigue, disorientation, confusion, and seizures.

If the provider documents the patient is experiencing ARF with either hypoxia or hypercapnia, you’ll select the appropriate code. However, you’ll assign J96.00 if the provider diagnoses ARF or J96.20 if the provider diagnoses acute-on-chronic respiratory failure without specifying the presence of hypoxia or hypercapnia.

Tip 3: Use Admission Reason to Sequence ARF and Another Condition

You may receive reports where the patient is admitted for respiratory failure and another acute condition. In these instances, the principal diagnosis won’t always be the respiratory failure or the other condition — the principal diagnosis will vary.

Scenario: A patient presents to the ED with a COVID-19 infection and is experiencing ARF. The physician documents that the patient’s ARF is a result of the COVID-19 infection.

In this case, you’ll assign U07.1 (COVID-19) and an appropriate J96.0- code, which follows the direction provided under ICD-10-CM Official Guidelines, section I.C.1.g.1.c.v. But “if ARF cannot be attributed to COVID (and COVID is not responsible for the admission), this rule doesn’t apply,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

If ARF cannot be attributed to COVID, then you’ll refer to ICD-10-CM Official Guidelines section I.C.10.b.3, which states “Selection of the principal diagnosis will be dependent on the circumstances of admission.” Palmer also notes that coders should also consider individual payer preferences when sequencing respiratory failure and another acute condition. “Coding according to the payer-specific guidelines is smart. You reduce the amount of denied claims by knowing the policies and guidelines of your payers,” Palmer says.

At the same time, if the provider’s documentation is unclear as to whether the ARF and another condition are equally responsible for the patient’s admission, you can query the provider for further confirmation.