We continue with our discussion of “Respiratory Failure, please refer to Part I for information on the clinical aspects and on the ICD-10-CM coding classification of this diagnosis. Often we think of “respiratory failure” as a condition occurring in the inpatient setting, but it can also occur in the Emergency Room, but usually results in an admission.

Medicare-Severity Diagnosis Related Groups (MS-DRGs): The determination of “respiratory failure” as the principal diagnosis is based upon the circumstances of admission AND the condition found after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. An inpatient encounter with a principal diagnosis code J95.821, Acute Postprocedural respiratory failure; J95.822, Acute and Chronic Postprocedural respiratory failure or ICD-10-CM codes J96.00-J96.92 for Respiratory Failure, Acute, Chronic, Acute and Chronic, Unspecified (without a procedure/surgery), will group to the following MS-DRG (ver. 38.0 for FY2021):

189 Pulmonary edema and respiratory failure (RW 1.2248, GMLOS 3.6)

The diagnosis of “Respiratory Failure” might also occur as a secondary diagnosis (additional diagnosis) and can be reported (coded) in the inpatient setting when the following occurs:

1. Clinically evaluated, or

2. Diagnostically tested, or

3. Therapeutically treated, or

4. Causes an increased Length of Stay (LOS) or nursing care and/or monitoring

Note that only one of the above has to be met or be present in the medical record in order to assign the secondary diagnosis for an inpatient encounter.

Medicare Advantage Risk Adjustment: Under Medicare Advantage (MA) Risk Adjustment (RA) we have certain ICD-10-CM codes that represent a “Hierarchical Condition Category or “HCC” to capture the patients’ health risk. Under MA-HCCs the condition must be documented within a face-to-face  encounter by an approved provider. In addition, the documentation must indicate that the condition (diagnosis) was managed, evaluated, or assessed or treated in order for the ICD-10-CM HCC to be  compliant.  Respiratory failure diagnosis codes are within HCC 84, Cardio Respiratory Failure and Shock.

Clinical Documentation Integrity (CDI):  CDI of course has a primary focus of querying the provider on a concurrent basis for most CDI program, although Outpatient CDI is occurring more often now also. It’s vital that the CDI program have in place a strong query policy and process in order to address documentation issues surrounding the specific diagnosis of respiratory failure. The query process should address the lack documented severity or degree of respiratory failure as well as the cause. When querying the provider regarding their documentation, we must follow the AHIMA/ACDIS Practice Brief regarding “Guidelines for Achieving a Compliant Query” and the AHIMA “Standards of Ethical Coding.”

· Some handy tips that I like to follow and remember regarding respiratory failure are:

· Acute and Chronic Conditions: If the same condition is described (documented) as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

· Review the clinical documentation carefully, this includes the clinical indicators and specific values of the respiratory system (i.e., hypoxemia or hypercapnia).

· There is a total of twelve ICD-10-CM codes for the classification of Respiratory Failure, so use caution and double check before making a final code selection.

· The ICD-10-CM  alphabetic index AND the tabular list must also support the code selection.

· Chapter specific rules and guidelines in the Respiratory System are found in Chapter 10 and those at the very beginning of the chapter apply to all codes within that chapter.

· Per Chapter 10, assign an additional code(s) where applicable to identify exposure to environmental tobacco smoke, or exposure to  tobacco smoke in the perinatal period, or history of smoking.

· Not all conditions occurring during surgery, following surgery or medical care are complications and thus the provider may need to be queried for clarification.

· Having a process in place for querying the provider regarding missing or unspecific documentation is a vital step to accuracy clinical coding.

Now that you’ve got a better understanding (or a refresher) of Respiratory Failure diagnosis and coding, this means that coding audits should be conducted as well. Coding audits are a vital component of healthcare compliance and as such need to be performed on a regular basis to ensure documentation and coding accuracy. Coupled with coding audits is “EDUCATION”, not only for the Coding and CDI staff but also to the   providers.  Make sure with each audit that is performed that you also have in place a process to provide education. Sharing the audit finding, and the “why” something occurred will be important to obtain improvements and maintain accuracy.


Okay, let’s now all take a deep breath!  As I end this article, I’d like to share with you this quote that I often keep in mind when addressing clinical documentation, coding and querying activities and their functions; “The time is always right to do what is right” – Martin Luther King Jr.

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer