Respiratory Failure
Definition: Syndrome where the respiratory systems fail in either or both the gas exchange function or oxygenation and carbon dioxide elimination. Recognized as either hypoxemic or hypercapnic.
Coding Considerations:
Review the circumstances of admission and etiology of Acute Respiratory Failure regarding assignment as principal vs secondary diagnosis. Be aware of chapter specific coding guidelines which provide sequencing guidance such as obstetrics, poisoning, HIV, and newborn.
Also note: All forms of respiratory failure, even ‘unspecified,’ map to an HCC in Risk Adjustment coding
Acute Respiratory Acidosis is now indexed to Acute respiratory failure with hypercapnia (J96.02) an MCC, chronic respiratory acidosis index to chronic respiratory failure with hypercapnia (J96.12) a CC and respiratory acidosis codes to acidosis NOS (E87.29) a CC.
CDI Practice Considerations
Acute Respiratory Failure is a highly targeted diagnosis in denials. In addition to blood gas impairments, patients with acute respiratory failure should display some signs/symptoms of difficulty breathing such as: inability to speak in complete sentences, accessory muscle usage, presence of retractions, tachypnea or slowed breathing rates, breath sounds described as grunting or wheezing, or the presence of cyanosis. If unresponsive to or delayed treatment patients may also develop neurologic indications such as anxiety, confusion, restlessness, seizures, somnolence, or coma.
Mechanical Ventilation is not a requirement to diagnosis Acute Respiratory Failure, however, is a strong indicator to consider when querying along with initiation of BiPAP therapy (i.e., not used at night for routine OSA). If the patient is intubated and placed on mechanical ventilation, track the time closely ensuring documentation supports precise intubation and extubation times for accurate PCS code and MS-DRG assignment.
P/F ratios are extremely helpful for CDS’s to determine if the patient meets criteria for Acute Respiratory Failure while receiving oxygen supplementation. Further it can be a powerful tool when providing education to providers when SpO2 levels may be ‘normal’ with supplemental oxygen. It is a simple calculation:
*It is inappropriate to calculate P/F ratio’s if the patient is on home oxygen therapy.
Generally accepted prediction models indicate that for every liter of oxygen supplied, the FiO2 increases by 4%.
1L = 24%
2L = 28%
3L = 32%
4L = 36%
5L = 40%
6L = 44%
Review the oxygen delivery type (NC, NRB, HFNC etc.) with flow rates closely to determine FiO2. Generally, a FiO2 of 36% or higher could be a clinical indicator for acute respiratory failure.
Acute respiratory insufficiency, acute pulmonary insufficiency, acute respiratory distress, and hypoxia do not code to acute respiratory failure. Review the record for clinical indicator support and query, as necessary.
Review clinical indicators for diagnostic criteria for Acute Respiratory Failure or Chronic Respiratory Failure when “respiratory acidosis” is documented, querying as necessary.
SpO2 ≤ 88% is a generally accepted criteria to qualify for home oxygen use, therefore when a patient requires continuous oxygen support, it is a reliable clinical indicator for chronic hypoxemic respiratory failure.
Not every patient who has COPD has chronic respiratory failure. Therefore, it is still appropriate to apply diagnostic criteria for Acute hypoxic and/or hypercapnic respiratory failure when reviewing for potential query opportunities.
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