Pulmonology Coding Alert

Follow the guidelines to code ARF correctly.

Respiratory failure means the condition wherein the lungs are no longer able to provide the requisite amount of oxygen to the body. The fine balance of carbon dioxide and oxygen in the lungs and the body gets disrupted, often leading to fatal consequences if not treated.

“Coders must be aware of the clinical nuances of respiratory failure that can qualify the patient’s condition, and provide for more specific ICD-10-CM coding,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

Basics first: While ICD- 9-CM offered a limited selection of three codes for the condition, ICD-10-CM now gives a plethora of codes to pick from. As you can see in the comparative chart, for each type of respiratory failure (acute, chronic, or acute and chronic), you now have three options: with hypoxia, with hypercapnia, and unspecified.

On top of this, you also have an additional “unspecified respiratory failure” option in your coding arsenal.

Make the Best of the Coding Guidelines

As you are aware, codes under pulmonology (typically referred to as the respiratory system) are covered in Chapter 10 of ICD-10, Diseases of the Respiratory System (J00-J99). While a majority of respiratory codes are found within the J00-J99 code range, you will find some listed in other chapters and sections of the code book.

There are few specific guidelines for the chapter on respiratory conditions. You do learn that conditions affecting the respiratory system may fall in one of three categories:

• Acute (with a sudden onset)
• Chronic (ongoing for three months or more)
• Recurrent (a condition that occurs more than once).

Practice Coding Different Cases

When coding acute respiratory failure as a primary diagnosis, you can start by assigning J96.0- or J96.2-. From there, you will need to heed other chapter specific coding guidelines.

When you come across acute respiratory failure as a secondary diagnosis that is occurring with another acute condition, your principal diagnosis will be decided based on the cause of admission. According to the coding guideline that provides information for acute respiratory failure, if respiratory failure is the chief cause for the medical visit, this will be your primary diagnosis. The condition can be both acute and chronic in nature, and can be documented using J96.0 (Acute respiratory failure) or J96.2 (Acute and chronic respiratory failure). Even though an associated condition can arise, acute respiratory failure can still be listed as the primary reason for the visit.

A plain respiratory failure with no specifications can be safely coded as J96.90. Further, based on the arterial blood gas report, you can add the fifth character: 1 for hypoxia, 2 for hypercapnia, or 0 for unspecified.

Remember: “Hospital coding (i.e., DRG) follows the ICD-10 coding convention more explicitly,” says Pohlig. If there are certain conditions that warrant use of other chapter specific guidelines such as poisoning, HIV, newborn, obstetrics, you must follow those on priority, as these conditions will take precedence. In such cases, if ARF (acute respiratory failure) occurs after admission, it will be a secondary diagnosis. Even when ARF is present on admission, you must make sure it’s not listed as the primary reason for the hospitalization.

Example: Imagine that a patient presents with ARF and another acute condition such as Myocardial Infarction (MI). In this case, hospital versus physician reporting may differ. The principal diagnosis (for the hospital claim) will depend on the condition that was responsible for the patient’s admission for medical services. When in doubt, it is better to ask the provider for clarification.

“The pulmonologist’s professional claim will list ARF as the primary diagnosis while the cardiologist will list MI as the primary diagnosis,” explains Pohlig. “The payers will need this distinction on the professional claims to justify the medical necessity for each service. If both providers listed MI as the primary diagnosis, the pulmonologist’s claim will be denied for concurrent care.”

Take note of Excludes1: Do not forget the Excludes1 note, meaning that you cannot possibly code respiratory failure with any of these conditions: acute respiratory distress syndrome (J80), cardiorespiratory failure (R09.2), newborn respiratory distress syndrome (P22.0), postprocedural respiratory failure (J95.82-), respiratory arrest (R09.2), respiratory arrest of newborn (P28.81), and respiratory failure of newborn (P28.5).