Case 1: A 72 year old patient with severe COPD and history of CHF has uncomplicated bowel resection for colon cancer. He requires three days of mechanical ventilation for respiratory failuer due to decompensated systolic heart failure and COPD.  

Case 2: A 55 year old patient with CAD undergoes CABG. He is on a ventilator following surgery and extubated within 24 hours with no apparent respiratory complications. “Ventilator dependent respiratory failure” is documented by intensivist following surgery in the ICU.

Should respiratory failure be coded as a secondary diagnosis and what codes should be assigned?

Understanding when to correctly and compliantly assign the postprocedural respiratory failure codes J95.821 and J95.822 is challenging. Because these codes are designated as MCCs, they are associated with a substantial increase in DRG reimbursement. On the other hand, these conditions are also classified as patient safety indicators (PSI 11) but only when associated with elective surgeries.

Case 1: Respiratory failure following surgery in other conditions

The ICD-10 Tabular listing for J95.82-, Acute postprocedural respiratory failure, has an Excludes1 note: “Respiratory failure in other conditions (J96-).” This indicates that codes J95.82- should not be assigned when postprocedural respiratory failure is attributed to a preexisting or other underlying condition. However, a similar Excludes1 note at category J96, Respiratory failure, NEC, includes "Postprocedural respiratory failure (J95.82-)” creating a circular exclusion for which there is no current explanation or coding advice.

Absent any further clarification, it appears that patients who have other preexisting or underlying conditions documented as the cause of respiratory failure following a procedure rather than a result of the procedure, may be assigned to category J96, Respiratory failure, NEC, together with the associated condition instead of codes J95.821 and J95.822 for post-procedural respiratory failure.

This would result is assignment of codes J96.90, Unspecified respiratory failure, I50.23, Acute on chronic systolic heart failure, and J44.1, COPD with exacerbation, as secondary diagnoses in Case 1.

Case 2: Postoperative respiratory failure not supported by the medical record

Some physicians have been inclined to document a diagnosis of respiratory failure or similar terms when patients require ventilator support which is an expected or a routine practice following the procedure with no apparent evidence of an acute pulmonary problem. Such documentation practices are problematic because the assignment of these codes which are MCCs may result in improper DRG payment.

To validate the diagnosis, the patient must have acute pulmonary dysfunction requiring non-routine aggressive measures. A patient who requires a short period of routine ventilator support during surgical recovery does not have acute respiratory failure, and a code for it should not be assigned on the claim.

Since Medicare does not permit hospitals to submit claims with codes for conditions that cannot be clinically validated, how should the CDS or coder handle such situations?

To validate the diagnosis, the patient must have acute pulmonary dysfunction requiring non-routine aggressive measures.  A patient who requires a short period of routine ventilatory support during surgical recovery does not have acute respiratory failure, and a code for it should not be assigned on the claim.

In discussing post-op mechanical ventilation, Coding Clinic 2006, Quarter 2, page 8 states: "A code should not be assigned for the mechanical ventilation when it is considered a normal part of surgery."

Following this same logic, a code should not be assigned for respiratory failure following surgery when mechanical ventilation is considered a normal part of surgery (routine, expected), unless there is verifiable clinical evidence of an acute pulmonary or other complicating condition actually causing respiratory failure.

Therefore in Case 2, even though the provider documented "Ventilator dependent respiratory failure", a code for respiratory failure (post-op or otherwise) would not be assigned since the diagnosis is not substantiated and the patient was "routinely" extubated within 24 hours having had no apparent respiratory complications.

Hospitals should have a specific written policy addressing situations where a diagnosis documented by a provider cannot be clinically substantiated by verifiable evidence within the medical record. It is no longer acceptable to simply assign codes for documented conditions that cannot by clinically validated. To do so risks regulatory scrutiny with possible sanctions or penalties on the hospital.