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Mechanical Ventilation for Airway Protection
Published on
Wednesday, September 14, 2022
Question
The patient presented with seizures and was intubated in the ED. The physician documented "acute respiratory failure" on the H & P, noting "Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight. Attempt to wean and extubate when no longer having seizures". On a progress note, "Acute Respiratory Failure” and “Respiratory failure-intubated in ED for airway protection. Maintain on ventilator overnight" was documented. On the Discharge Summary, "Acute Respiratory Failure. Respiratory failure-intubated in ED for airway protection. Now extubated. Doing well" was documented. Based on the documentation, should we code the Acute Respiratory Failure as a secondary diagnosis, query for clarification, or leave it off since it was "for airway protection"?
Answer
If a patient is intubated for airway protection, and Acute Respiratory Failure is documented, a code for the Acute Respiratory Failure can be assigned. However, if a patient is intubated for airway protection and there is no documentation of Respiratory Failure, coders cannot assume or assign a code for Respiratory Failure, just because the patient was intubated and placed on a mechanical vent.
Remember to also code the procedure codes for the Mechanical Ventilation and ETT, if appropriate.
References
Coding Clinic for ICD-10-CM/PCS, Third Quarter 2012: Page 21
Article Author: Susie James, RHIT, CCS
Susie James, RHIT, CCS, is the Manager of Inpatient Coding Services at MMP, Inc. Susie has worked in the coding field for over 30 years and has worked as a coder, coding supervisor, and corporate coding manager for a large multi-facility system in Birmingham. She also worked for Alabama Quality Assurance Foundation (AQAF) as a coding reviewer/auditor before joining the team at Medical Management Plus, Inc. Susie has previously served as the President of the Alabama Association of Health Information Management (AAHIM) on the Board of Directors and currently serves as the Education/Coding Roundtable Chair. She is also a member of the American Health Information Management Association (AHIMA) and has previously served as the Co-chair for AHIMA's Leadership Team. She also served as a facilitator at AHIMA's 85th National Convention in Atlanta Georgia.
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.
