Otolaryngology Coding Alert

Question: What diagnosis codes should I report for a 32-year-old woman with acute respiratory distress? Should I assume the provider means respiratory distress syndrome (RDS)?

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Answer: As a coder, you should never make assumptions or inferences into what the provider may or may not be thinking when assigning a diagnosis. With this in mind, you should not assume that the patient is experiencing RDS as opposed to an acute episode of respiratory distress.

RDS in adults is a severe condition involving an accumulation of fluid buildup in the lungs. On the other hand, acute respiratory distress is a more generalized diagnosis that’s not necessarily indicative of RDS. This is especially important because of the respective codes you should report for each condition. In the case of this patient, you use the index to identify Distress ⇒ acute respiratory ⇒ R06.03 (Acute respiratory distress). Keep in mind you would reach the same code for a diagnosis of unspecified respiratory distress. Unless the syndrome is specifically documented, you should not consider J80 (Acute respiratory distress syndrome) in any instance involving acute respiratory distress.