NEONATE RDS vs. ACUTE RESPIRATORY FAILURE

macdonm

In Neonate population, when RDS and Acute Respiratory Failure are present and documented ,  Is it acceptable to code Acute Respiratory failure over RDS as SDX ?  Does the exclude one note allow you to choose the optimal diagnosis when both diagnoses co-exist and are documented?     Also,  if you do select the Acute Respiratory Failure, what do you do once that is resolved?   What happens to the RDS?      Thank you.   

Amy_Stremming_1992

At our facility, we have discussed this issue numerous times with our coders and physicians. Our coders code RDS if both are documented *unless* the respiratory failure develops after RDS or is due to another cause. If the respiratory failure is due to the RDS, they only code RDS. They feel if the reason for the failure is known and due to RDS, then based on the excludes one note, the RDS must be the only diagnosis coded.

Aknize

At our facility, we code the respiratory failure, or if they are using them interchangeably, we query to determine which the physician wishes to diagnose.  Some charts mention ttn, rds and resp failure (all in the same chart, depending on who wrote the note).  If the respiratory failure is supported, then we code it.   

julian.everett

Our physician barely note acute respiratory failure on our neonates. However, if I had to choose I would go for RDS because that’s the cause of the acute respiratory failure .