Acute Respiratory Disctress Syndrome (ARDS) & Respiratory Failure

chwcdi

Our CDI team created a query template for Acute Respiratory Distress Syndrome (ARDS) and have gotten provider responses to this query confirming the diagnosis. However, it appears that per Coding Guidelines you cannot code both ARDS and respiratory failure together. Our question is this: Does your institution pursue documentation and capture of ARDS (especially in the setting of respiratory failure)?

jackietouch@aol.com

We do, especially on patients who require inhaled nitric oxide (iNO) therapy. Our iNO policy specifies pulmonary hypertension and ARDS as indications for therapy (in non-neonates) so if a patient is receiving iNO and there is no documentation of indication why, we clarify if the indicators and risk factors are present. Not sure if this has helped with denials, but we clarify in order to assist utilization/case management department.

afrady@blr.com

The entire J96 ICD category for Respiratory Failure is an excludes 1 with J80 for ARDS.   This means that the two conditions cannot be reported together UNLESS they are due to unrelated pathophysiological processes.  This means they will usually not be reported together.

An example of an exception would be a patient who comes in with respiratory failure from pneumonia present on admission yes and subsequently develops ARDS due to shock/sepsis or barotrauma could receive ICD 10 code J80 with a POA of N.    This is because pneumonia caused respiratory failure but shock or barotrauma caused the ARDS, and that is the key.

In order for the coder to override the excludes 1 note, guidelines require it be very clear that the two conditions are unrelated clinical processes, which is often absent the record.   Even when written clearly, less trained and less confident coders may still fail to apply this coding rule and report both conditions on the same episode of care.

Another word of caution; be VERY CAREFUL reporting ARDS.  ARDS is an independent diagnosis which requires a true and demonstrable intra-pulmonary pathology and is not appropriate for patients who simply have trouble weaning from the vent.   Were I an auditor and I noticed J80 being used without clear documentation of an intrapulmonary process I would target you for denials.

ARDS generally only occurs in things like trauma, shock, massive PE,  sepsis, poor surgical outcomes or NICU premie populations.    We used to do it with patients due to baro-trauma from venting with too much pressure but that has greatly decreased over the years.

RPinson@PinsonandTang.com

Good discussion above.  Would also like to add a few comments. As noted in the 2018 CDI-PG:

ARDS, also known as acute lung injury (ALI) , is a specific pathologic condition having certain clinical characteristics causing acute respiratory failure, often severe. ARDS is recognized primarily by the

PO2/FIO2 ratio:

• Mild: P/F ratio = 200—300

• Moderate: P/F ratio = 100—200

• Severe: P/F Ratio < 100

The usual x-ray picture is a more or less a bilateral symmetrical pulmonary edema, not localized or unilateral. Pulmonary edema due to left heart failure is not ARDS but may have very similar symptoms

and x-ray pattern, and must be excluded as the cause.

Typical causes of ARDS are sepsis, aspiration, prolonged shock, and multiple, severe trauma. Others include post-cardiopulmonary bypass, difficult prolonged surgery, multiple transfusions, fat embolism, and

fulminant pancreatitis.

You need both the X-ray findings and characteristic clinical setting to support a diagnosis of ARDS.  If it looks like a patient probably has undocumented ARDS (an unlikely situation), we would recommend a query.

Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com