Pulmonology Coding Alert

Question: I have a physician’s note that documents the patient’s conditions as acute respiratory failure with hypoxia as well as hypoxemia. I feel like J96.01 covers both conditions, but I’m also thinking I should report each condition separately.

Could you please walk me through coding this documentation?

Nevada Subscriber

Answer: For scenarios like the one you’re describing, the answer depends on the documentation. You will certainly use J96.01 (Acute respiratory failure with hypoxia) to report the respiratory failure with hypoxia, but whether you code hypoxemia will depend on the wording in the physician’s note.

Hypoxemia is a decrease in the oxygenation level of the patient’s blood, whereas hypoxia is a low level of tissue oxygenation. The two symptoms are similar, but not the same. A patient could potentially experience the two symptoms together, but it’s not a foregone conclusion.

Patients suffering from respiratory failure with hypoxia can also experience hypoxemia, as the latter can be a symptom of respiratory failure, too. If the patient experiences both symptoms related to a diagnosis, then you can use a combination code.

A combination code is a single code that you’ll use to report:

• Two diagnoses
• A diagnosis with a related secondary process (manifestation)
• A diagnosis with an associated complication

ICD-10-CM code J96.01 is a combination code that includes hypoxia. This combination code may cover hypoxemia if it is a symptom of the respiratory failure.

Guidance in “Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)” of the ICD-10-CM code set indicates that codes for “symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.”

Code R09.02 (Hypoxemia) falls under a category of codes that describe a symptom or sign. Therefore, you should not report the code separately if it is a symptom of the respiratory failure, which can be the case, as physicians commonly find hypoxemia in patients with respiratory failure with hypoxia. However, if the provider’s documentation indicates the hypoxemia source is unrelated to the respiratory failure, then you can code the symptom separately.