ETOH withdrawal and ARF sequencing.
I have a current case with a patient who was found down at home unresponsive with a GCS of 5. She was intubated and brought to the ER and carries current dx of Acute respiratory failure and ETOH withdrawal, along with other co-morbidities. We are discussing sequencing options. Pdx of withdrawal vs ARF. I am reviewing the sequencing guidelines for ARF (again). Would you agree that the withdrawal should be Pdx based on this guidance:
2. When a patient is admitted in respiratory failure due to/associated with an acute exacerbation of a chronic nonrespiratory condition, that condition is the principal diagnosis.
Example:
Following dietary indiscretion, a patient with compensated congestive heart failure developed paroxysmal nocturnal dyspnea, orthopnea, and pedal edema leading to increased respiratory distress. In the emergency room the patient was found to be in cardiogenic pulmonary edema and respiratory failure and was subsequently intubated in the emergency room. The patient was admitted and treated for congestive failure. No myocardial infarction was found.
Principal diagnosis:
428.0 Congestive heart failure
Additional diagnosis:
518.81 Respiratory failure
In this example, the congestive heart failure had become acute and required immediate hospital care. The associated development of respiratory failure in this case is an additional complicating factor, but is not the condition that occasioned the admission and should not be designated as the principal diagnosis.
3. When a patient is admitted with respiratory failure due to/associated with an acute nonrespiratory condition, the acute condition is sequenced as the principal diagnosis.
Example A:
A patient was seen in the emergency room with chest pain and shortness of breath and was intubated. The patient was admitted and subsequently diagnosed as having an acute subendocardial myocardial infarction complicated by respiratory failure.
Principal diagnosis:
410.71 Acute subendocardial infarction, initial episode
Additional diagnosis:
518.81 Respiratory failure
In this example, the acute myocardial infarction (AMI) required admission and is the principal diagnosis, even though the respiratory failure developed prior to the admission and required immediate attention.
Example B:
A patient experienced a cerebrovascular thrombosis, and upon arrival at the hospital was found to be in acute respiratory failure. The patient was placed on mechanical ventilation and admitted to the intensive care unit for further care for the respiratory failure and management of the cerebrovascular thrombosis.
Principal diagnosis:
Note from 3M:
As of October 1, 1993, code 434.0 has been expanded to fifth digits to indicate with or without cerebral infarction.
434.0 Cerebral thrombosis
Additional diagnosis:
518.81 Respiratory failure
In this example, the cerebrovascular thrombosis was the reason for admission to the hospital. The respiratory failure, while requiring additional intensive treatment, was not the condition that led to admission, but rather a complication of that condition.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
2. When a patient is admitted in respiratory failure due to/associated with an acute exacerbation of a chronic nonrespiratory condition, that condition is the principal diagnosis.
Example:
Following dietary indiscretion, a patient with compensated congestive heart failure developed paroxysmal nocturnal dyspnea, orthopnea, and pedal edema leading to increased respiratory distress. In the emergency room the patient was found to be in cardiogenic pulmonary edema and respiratory failure and was subsequently intubated in the emergency room. The patient was admitted and treated for congestive failure. No myocardial infarction was found.
Principal diagnosis:
428.0 Congestive heart failure
Additional diagnosis:
518.81 Respiratory failure
In this example, the congestive heart failure had become acute and required immediate hospital care. The associated development of respiratory failure in this case is an additional complicating factor, but is not the condition that occasioned the admission and should not be designated as the principal diagnosis.
3. When a patient is admitted with respiratory failure due to/associated with an acute nonrespiratory condition, the acute condition is sequenced as the principal diagnosis.
Example A:
A patient was seen in the emergency room with chest pain and shortness of breath and was intubated. The patient was admitted and subsequently diagnosed as having an acute subendocardial myocardial infarction complicated by respiratory failure.
Principal diagnosis:
410.71 Acute subendocardial infarction, initial episode
Additional diagnosis:
518.81 Respiratory failure
In this example, the acute myocardial infarction (AMI) required admission and is the principal diagnosis, even though the respiratory failure developed prior to the admission and required immediate attention.
Example B:
A patient experienced a cerebrovascular thrombosis, and upon arrival at the hospital was found to be in acute respiratory failure. The patient was placed on mechanical ventilation and admitted to the intensive care unit for further care for the respiratory failure and management of the cerebrovascular thrombosis.
Principal diagnosis:
Note from 3M:
As of October 1, 1993, code 434.0 has been expanded to fifth digits to indicate with or without cerebral infarction.
434.0 Cerebral thrombosis
Additional diagnosis:
518.81 Respiratory failure
In this example, the cerebrovascular thrombosis was the reason for admission to the hospital. The respiratory failure, while requiring additional intensive treatment, was not the condition that led to admission, but rather a complication of that condition.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
I believe the info below is from CC 2nd Qtr 1991 which has been superceded by info in CC 1st qtr 2005 which leaves the door open for different options. If it is a poisoning, then acute respiratory failure will be secondary.
Code 518.81, Acute respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence. Respiratory failure may be listed as a secondary diagnosis if it occurs after admission.
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident), the principal diagnosis will not be the same in every situation. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are responsible for occasioning the admission to the hospital, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C,) may be applied in these situations.
The advice above supercedes guideline #1 and guideline #2, previously published in Coding Clinic, Second Quarter 1991, page 3. This information is consistent with advice previously published in Coding Clinic, November-December 1987; Second Quarter 1990, page 11-12; Third Quarter 1991, page 14; First Quarter 1993, page 25;Second Quarter 2000, page 21; and First Quarter 2003, page 15.
Respiratory failure is a life-threatening condition that is always due to an underlying condition. It is usually the final pathway of a disease process, or a combination of different processes. It can arise from an abnormality in any of the components of the respiratory system, central nervous system, peripheral nervous system, respiratory muscles and chest wall muscles. Patients with acute respiratory failure require repeated assessments and close observation. The primary thrust of treatment is usually towards correction of the hypoxemia and stabilization of the ventilatory and hemodynamic status
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org