Pulmonology Coding Alert

Hint: Post-procedural respiratory failure should still be reported differently as in ICD-9.

Your pulmonologist will frequently review patients for dyspnea (shortness of breath). While reasons for dyspnea are varied, a more serious one is acute respiratory failure. You’ll need to delve deep into documentation to identify presence of hypoxia or hypercapnia, as this will affect the way you report the diagnosis of acute respiratory failure in ICD-10 codes.

Use Two ICD-9 Codes For Respiratory Failure Depending on Cause

When your pulmonologist diagnoses acute respiratory failure, you have two code choices in ICD-9 based on what has caused the condition. If the failure has occurred secondary to trauma or a surgical procedure, you will have to report the diagnosis with 518.51 (Acute respiratory failure following trauma and surgery). You will have to use 518.81 (Acute respiratory failure) to report acute respiratory failure when it occurs due to any other cause.

Reminder: You cannot use 518.81 to report a diagnosis of acute respiratory failure if it occurs as an acute episode on a patient already suffering from chronic respiratory failure. In such a condition, you will have to report the diagnosis with 518.84 (Acute and chronic respiratory failure). If the acute respiratory failure is due to any infection, don’t forget to identify the infectious organism using an additional code.

Check For More Options in ICD-10

When you begin using ICD-10 codes, a diagnosis of acute respiratory failure will have to be reported with J96.0- (Acute respiratory failure).  Based on the presence or absence of hypoxia or hypercapnia, J96.0 further expands into the following three 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)

Watch out: J96.0- cannot be used if your pulmonologist diagnoses respiratory failure due to a post-procedural complication (J95.82-). You also should not use J96.0- if the diagnosis is acute respiratory distress syndrome (J80), cardiorespiratory failure (R09.2), or respiratory arrest (R09.2)

Focus on These Basics Briefly

Documentation spotlight: Some of the acute respiratory failure signs and symptoms that you are more likely to find in the patient documentation will include dyspnea, anxiety, restlessness, loss of consciousness, confused state and presence of seizures.

Upon examination, your pulmonologist might note the presence of crackles during auscultation, tachycardia and the presence of cyanosis. Whenever your pulmonologist diagnoses acute respiratory failure, he will try to identify the cause for the condition. For example, a pulmonary cause for failure will include pneumonia, asthma or COPD. Alternately, your pulmonologist might look for a cardiogenic or for a renal cause for the respiratory failure.

Your pulmonologist will diagnose acute respiratory failure beginning with history and signs and symptoms. Once he suspects acute respiratory failure, he will withdraw an arterial blood sample and send it to the laboratory to check for arterial blood gases to record arterial oxygen tension (PaO₂) and arterial carbon dioxide tension (PaCO₂). “An elevated PaCO2 above the normal range, 35-45 mmHg, would indicate the presence of hypercapneic respiratory failure. Some would not diagnose respiratory failure unless the PaCO2 is 50 mmHg or above,” says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. “If the PaO2 is less than 60 mmHg on air or if the patient requires oxygen to keep the PaO2 above 60 mmHg, then the patient has hypoxic respiratory failure.” Some of the other lab tests that will be performed will include a complete blood count, liver function tests and kidney function tests that will help identify the cause for the respiratory failure.

Apart from this, your pulmonologist will order for a chest x-ray (this again helps in identifying cause for failure), and echocardiography.

Example: Your pulmonologist assesses a 58-year-old male asthmatic patient for complaints of severe dyspnea and restlessness. Your pulmonologist performs a comprehensive history taking and then proceeds to examine the patient. During examination, the patient appears confused and in a state of anxiety. Your pulmonologist notes presence of cyanosis and tachycardia. Upon auscultation, he notes the presence of fine crackles. At the end of the examination, the patient starts to lose consciousness and has severe difficulty in breathing on his own and is immediately put on respiratory support.

Suspecting respiratory failure, your pulmonologist sends an arterial sample for analysis of blood gases. He also orders for a chest x-ray and echocardiography. He also asks for CBC, kidney and liver function tests.

The results of blood gas analysis return with a PaCO₂ > 50 mm Hg and chest x-ray appears clear. The results from other tests did not detect any severe deviations from normal.

Your pulmonologist arrives at a diagnosis of acute respiratory failure caused from exacerbation of the asthma.

What to report: With supporting documentation, you may report the evaluation of the patient with 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components…), and J96.02 if you are using ICD-10 codes or 518.81 if you are using ICD-9. You need to use J96.02 as PaCO₂ values were higher than 50mm of Hg indicating hypercapnia.