I understand the difference between the two, but I've seen both coded together. Ex: acute respiratory failure w/hypoxia (J96.01) and hypoxemia (R09.02); hypoxia coded by itself is the same code as hypoxemia. Would using both J96.01 and R09.02 be considered unbundling, or would it depend on the documentation?
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Wiki Hypoxia vs hypoxemia
- Thread starter bjkaseman
- Start date
thomas7331
Guest
First of all, 'unbundling' is a concept that applies to procedure coding, not diagnosis coding, so that is not an issue here. As to whether or not both codes should be reported would depend on documentation.
ICD-10 guidance specifies that codes for "symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider". Since R09.02 falls under the category of codes that describe a symptom or sign, the question here would be whether or not the hypoxia in this patient's record is a symptom of the respiratory failure. I would expect that hypoxemia would commonly be found in patients with respiratory failure with hypoxia so I would not routinely code this separately. But in an unusual case, for example if the provider has documented that they are investigating a potential source of hypoxemia that is unrelated to the respiratory failure, then in that case it might be appropriate to code this separately.
ICD-10 guidance specifies that codes for "symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider". Since R09.02 falls under the category of codes that describe a symptom or sign, the question here would be whether or not the hypoxia in this patient's record is a symptom of the respiratory failure. I would expect that hypoxemia would commonly be found in patients with respiratory failure with hypoxia so I would not routinely code this separately. But in an unusual case, for example if the provider has documented that they are investigating a potential source of hypoxemia that is unrelated to the respiratory failure, then in that case it might be appropriate to code this separately.
Thanks for your quick response. I should have used the term: combination code as opposed to unbundling. I appreciate the correction which now holds a special place in my memory; I'll never forget it. The physician did document respiratory failure w/hypoxia as well as hypoxemia. At the time I felt the combination code J96.01 covered both conditions, but you're right, it depends on the documentation. Thanks again for your help.