Respiratory failure due to both RDS and also maternal anesthesia
in Pediatrics
Based on coding clinic, when respiratory failure is due to RDS you code the more specific RDS. There is an edit when you code for both stating that if the two are unrelated you can code for both. I had a query response for the etiology of respiratory failure as both, due to RDS and due to maternal anesthesia and clinically was supported. Because the respiratory failure is due to both (two causes) it seems that we then could code for both. There is discussion amongst us as CDI and coding and seeking input for educational purposes as I may be interpreting this coding clinic wrong? I actually have seen this previously in our facility and it just makes sense we could but I like facts as I may be wrong. Thank you!
Comments
Correct. The excludes 1 note on this does not preclude you from coding both as long as you have strong documentation to support it. This also occurs when a neonate has clear documentation of resolved RDS (something Neo CDIs should be looking for and encourage in documentation) and subsequently the infant develops a separate respiratory condition unrelated to the RDS and then has respiratory failure. In this instance, both would be coded as well.