Coding and Sequencing Guidelines for Respiratory Failure

on Tuesday, 13 May 2014. All News Items | Coding



For updated information on this topic, please click here for the more recent article: Coding Guidelines for Respiratory Failure

Whether it’s ICD-9-CM or ICD-10-CM, the coding guidelines are actually the same for Respiratory Failure. The only difference is the code itself. It’s not only important for a coder to be familiar with these guidelines but also some of the basic clinical indicators as well.


from Section II of the Official ICD-9-CM Guidelines for Coding and Reporting

“Principal Diagnosis”
A condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care - defined by the Uniform Hospital Discharge Data Set (UHDDS).



Each admission is different. The Principal Diagnosis will not be the same in every situation. Selection of the Principal Diagnosis is dependent on the circumstances of the admission. Coders should ensure that the record contains documentation that indicates clinical credibility to support the presence of that condition. It is also important for coders to understand the clinical indicators of Acute and/or Chronic Respiratory Failure in order to establish a query when necessary.


Respiratory Failure

  1. Life-threatening condition that may be caused by a respiratory condition as well as a non-respiratory condition.
  2. Look for documented signs / symptoms of:
    • SOB (shortness of breath)
    • Delirium and/or anxiety
    • Syncope
    • Use of accessory muscles
    • Tachycardia
    • Tachypnea
    • Confusion
    • Sleepiness
    • Depressed consciousness
    • Cyanosis (bluish color to skin, lip and/or fingernails)
  3. Acute Respiratory Failure is supported as principal diagnosis when at least 2 of the following critical values (ABG’s) are met.
    • pH < 7.35
    • PO2 < 55
    • PCO2 > 50

    Keep in mind, this is a guideline and not solely to be the determining factor for   diagnosing Acute Respiratory Failure. A patient with a chronic lung disease such as COPD may have an abnormal ABG level that could actually be considered that particular patient’s baseline. What is normal for one patient could be abnormal for another. In a patient with a chronic lung condition, the physician would consider the degree of change from a patient’s baseline before diagnosing Acute Respiratory Failure.

  4. Acute Respiratory Failure
    • Develops quickly
    • Usually admitted to ICU
    • Requires aggressive and/or emergency treatment via oxygen through nasal cannula, face mask, ventilation and/or tracheostomy
    • Absence of vent does not preclude diagnosis
    • Requires close monitoring and evaluation
  5. Chronic Respiratory Failure
    • Develops slowly
    • Last longer
    • Home O2 is one indication of CRF

Four classifications types for ARF

  • Hypoxic – most common
  • Hypercapnia – often accompanied by hypoxemia
  • Post-operative
  • Shock – Septic, Cardiogenic or Hypovolemic

Acute Respiratory Failure as Principal Diagnosis


ICD-10-CM – Section I.C.10.b.1

(ICD-9-CM – Section I.C.8.c.1)

Codes in Section



518.81 or 518.84 subcategory J96.0 or subcategory J96.2

Acute or Acute on Chronic 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 selectionis supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.



ICD-10-CM – Section I.C.10.b.3

(ICD-9-CM – Section I.C.8.b.3)

Codes in Section



518.81 or 518.84 subcategory J96.0 or subcategory J96.2

When a patient is admitted with Respiratory Failure and another acute condition (e.g., Myocardial Infarction, Cerebrovascular Accident, Aspiration Pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission.   If both the Respiratory Failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II.C) may be applied in these situations.

If the documentation is not clear as to whether Acute Respiratory Failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.


When coding Respiratory Failure (or any condition) and trying to determine whether it should be assigned as principal diagnosis or not, look for:

  1. All signs and symptoms at the time of admission
  2. Clinical indicators
  3. Supporting physician documentation
  4. Treatment plans

With any record, keep in mind that because a condition may be present on admission does not necessarily mean if qualifies for principal diagnosis. You have to ask yourself these questions:

  • After study, is this the condition that was chiefly responsible for admission?
  • How aggressive was the work-up and treatment?
  • Is there another condition that equally meets the criteria for principal diagnosis?
  • Are there any chapter specific guidelines to consider?
  • Could this condition have been treated as an outpatient?

I wish I could say that assigning the appropriate principal diagnosis and coding in general was as easy as ABC, but it’s not. Some are a little easier than others but there seems to always be a little gray area to muddle through. Clear and precise documentation goes a long way in helping to determine the principal diagnosis.

As you take on a record to code, forget about the one you just finished. Each record and the circumstances surrounding the admission will be different.   Always be aware of the coding guidelines and follow through the steps listed above. You’ll find that assigning the principal diagnosis will be a little easier.

Article by Marsha Manning

Marsha Manning RHIT, CCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an Inpatient Coding Consultant at Medical Management Plus, Inc.  Marsha has over 24 years’ experience in the coding profession and has held various positions such as DRG coordinator, Coding Supervisor and HIM Supervisor. In her current position, Marsha reviews records and assists clients with coding accuracy, compliance, education and Case Mix Index (CMI) as they relate to specific entities concerning Medicare. You may contact Marsha at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

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