One of the more challenging areas of medical coding, is the diagnosis of “Respiratory Failure”. Not only does it take having a solid clinical understanding but also a succinct knowledge of the Official Guidelines for Coding and Reporting as well as knowing when to query for documentation specificity. Obtaining coding compliance does center around continually learning and enhancing one’s knowledge and skills. Although there is a volume of information on the subject of respiratory failure the following two-part article serves as a “refresher” that may prove to be helpful.

Clinical Aspects: Let’s start with some of the basics regarding the clinical aspects of respiratory failure, which includes the differences in “Acute vs Chronic” respiratory failure condition. In the human anatomy it is the lungs that are the primary organ of the respiratory system. We have two lungs (right and left) with a total of 5 sections or lobes; the left lung has two lobes and the right lung has three. We inhale and we exhale; the rate of breathing and the volume of each breath are extremely regulated to maintain constant values of CO2 tension and pH of the blood. Thus, it’s clinically important when the values or levels are not in the normal range.

• Acute respiratory failure comes on suddenly over a few hours or within a day or two from impaired oxygenation, impaired ventilation, or both. It’s important to review the documentation carefully and check to see if the RR (respiratory rate) is less than 20 or greater than 10; if there is any wheezing, and/or nasal flaring, accessory muscle use for breathing, as these are signs that can indicate acute respiratory failure is present.
• Chronic respiratory failure often develops slowly and is ongoing (months and years) due to the airways that carry air to the lungs being narrowed and damaged. A patient with COPD that has progressed to the end-stage often utilizes portable oxygen on a daily basis. The most common cause of COPD is smoking.
• Acute and Chronic respiratory failure includes both severities of the failure, and these can occur at the same time.

Often the cause of respiratory failure is related to the lungs themselves or to the heart. But some of the most common causes of “respiratory failure” are:

When respiratory failure does occur, the provider will want to identify the underlying cause as this will help with determining the initial and even long-term treatment. A patient with respiratory failure may experience hypoxia (not enough oxygen in the blood) or hypercapnia (too much carbon dioxide in the blood), thus it’s important to identify the clinical indicators in the medical record.

ICD-10-CM: In Health Information Management (HIM) and Clinical Documentation Integrity (CDI) the golden rule has two parts, first is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) AND second, we ALWAYS follow the Official Guidelines for Coding and Reporting, which can be located at the following site (for 2021): 2021 ICD-10-CM Guidelines (cdc.gov)

Chapter 10 of ICD-10-CM is titled, “Diseases of the Respiratory System” and has the code range of (J00-J99). This is where you can locate the chapter specific guidelines relating to the coding of Respiratory Failure; all of these guidelines should be reviewed and followed. NOTE that the guidelines state: When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site e.g., tracheobronchitis to bronchitis in J40. For coding conditions from Chapter 10 the following applies to all codes in the range of J00-J99:

Use additional code, where applicable, to identify:

• Exposure to environmental tobacco smoke (Z77.22)
• Exposure to tobacco smoke in the prenatal period (P96.81)
• History of tobacco use (Z87.891)
• Occupational exposure to environmental tobacco smoke (Z57.31)
• Tobacco dependence (F17.0-)
• Tobacco use (Z472.0)

In ICD-10-CM the classification of Respiratory Failure (J96) includes “acute (J96.0-)”, “chronic” (J96.1-). “acute and chronic” (J96.2-), and “unspecified” (96.9-), each are coded with hypoxia or hypercapnia or unspecified at the fifth character of the code. Become more familiar with these codes by reviewing the tabular code selections closely.

In part-2 of this article on Respiratory Failure we’ll discuss MS-DRGs, HCCs and Querying. For now, take a deep breath and remember to strive for accuracy and compliance at all times.

References: 2021 ICD-10-CM Guidelines (cdc.gov); AHA Coding Clinic for ICD-10-CM/PCS; RMC webinar, “Secondary Diagnosis Coding, Outpatient and Inpatient”, May 2018; MLN Matters® Number: SE1121 Revised, cms.gov; http://www.hcpro.com/HIM-263777-5707/Tip-Know-when-to-report-secondary-diagnoses.html; https://www.oxygen-review.com/respiration.html; https://medlineplus.gov/respiratoryfailure.html; https://www.nhlbi.nih.gov/health-topics/respiratory-failure ; Acute Respiratory Failure: Causes, Symptoms, and Diagnosis (healthline.com)