When an obstetrics condition (during pregnancy, delivery, or postpartum) causes respiratory failure, the obstetrics complication code is sequenced first and the code for
the respiratory failure is second.
3. Human Immunodeficiency Virus (HIV)–related condition. With an HIV-related condition such as pneumonia
in HIV causing respiratory failure, the HIV code is listed
as the principal diagnosis, with the related condition and
respiratory failure listed second.
4. Sepsis with respiratory failure. For sepsis with respiratory failure, the sepsis is listed as the principal diagnosis,
with the underlying disease and respiratory failure listed
second. In order to apply this guideline, the sepsis must be
present or suspected on admission. If the sepsis develops
later during hospitalization, the sepsis is listed as the secondary diagnosis code.
Coding Two or More Conditions that Equally Qualify
as Principal Diagnosis
When respiratory failure is one of two or more conditions that
equally qualify as the principal diagnosis code, either can be
listed as the principal diagnosis code—except in the situations
discussed in the previous section of this article.
This situation is typified when congestive heart failure (CHF)
causes acute respiratory failure. The criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, should dictate which
condition is selected as the principal diagnosis code. If both
conditions are considered to be equally treated, either can be
sequenced as the principal diagnosis code. If in doubt, query
the attending physician.
Coding Respiratory Failure with Respiratory Condition
When two or more conditions equally qualify as the principal
diagnosis code, the same analogy as in the previous section
of this article is applied to acute respiratory failure and a respiratory condition such as pneumonia, chronic obstructive
pulmonary disease with exacerbation, or other respiratory
conditions. In a situation in which the patient is emergently
admitted with acute respiratory failure and requires intubation
and mechanical ventilator support, and it is later determined
that the patient has aspiration pneumonia, coding guidelines
say that the criteria for principal diagnosis as determined by
the circumstances of admission, diagnostic workup, and/or
therapy provided should dictate which condition is selected
as the principal diagnosis code. In this case, it may be more
appropriate to list the acute respiratory failure as the principal
In another example, the patient is admitted with respiratory
failure and is found to have a pulmonary embolus, which is
treated with a vena cava filter. The pulmonary embolus should
be considered as the principal diagnosis code. In this case, the
respiratory failure is of secondary importance to the pulmonary
embolus, which requires invasive measures.
Coding Respiratory Failure in ICD-10-CM
ICD-10-CM provides for a distinction between acute respiratory
failure and unspecified respiratory failure, and it further allows for
the coding of respiratory failure with hypercapnia or hypoxemia.
Coding guidelines for principal diagnoses in ICD-10-CM are the
same as in ICD-9-CM. More comprehensive instruction is now given in the Centers for Medicare and Medicaid Services’ ICD-10-CM
Official Guidelines for Coding and Reporting, including instruction previously only given in the American Hospital Association’s
Coding Clinic publication. Coding and clinical documentation
improvement specialists must acknowledge that all prior coding
instruction given for ICD-9-CM applies to ICD-10-CM, and should
thus be very familiar with the prior coding instruction.
In the coding example at the beginning of this article, the patient’s blood gases and blood pH are not consistent with acute
respiratory failure, so the physician should be queried. The query should explain the clinical findings and ask for further clarification of the diagnosis.
In another case, a patient is admitted in acute respiratory failure
following a cardiac arrest. The patient’s blood gases show a pCO2
of 78 percent with a blood pH of 7. 28. The patient is intubated and
placed on mechanical ventilation. The patient’s family decides not
to pursue any further measures and wishes to place the patient on
comfort care only. The patient expires four days after admission.
Is it appropriate to list the acute respiratory failure as the principal
diagnosis code? Some would argue that the cardiac arrest was the
underlying cause of the respiratory failure and that should be listed as the final diagnosis code. The clinical indicators are certainly
present for acute respiratory failure. The coding guidance shows
that respiratory failure can stand alone as a diagnosis without the
necessity of listing the underlying cause first, so it should be acceptable to list the acute respiratory failure as the final diagnosis code.
Build Familiarity with Clinical Indicators
It is important to be familiar with the clinical indicators for acute
respiratory failure and understand the coding guidance to assign
the correct diagnosis codes. Sequencing of the diagnosis codes
can affect coding compliance and reimbursement. If coding decisions are based on the clinical documentation present, and prevailing coding guidelines, then the coded data will be accurate. ¢
Centers for Medicare and Medicaid Services. “ICD-10-CM
Official Guidelines for Coding and Reporting, FY 2019.”
Virtual Medical Care. “Respiratory failure (types I and II).” June
Monica Leisch ( email@example.com) is director of compliance/HIM
services at Healthcare Cost Solutions.