Documenting and Coding Acute Respiratory Failure (ARF)

by | Aug 1, 2018 | Blog, Medical Coding

Respiratory failure refers to a syndrome which occurs when the respiratory system fails in one or both of its gas exchange functions – oxygenation and carbon dioxide elimination. The condition happens when the capillaries or tiny blood vessels (surrounding your air sacs) can’t properly exchange carbon dioxide for oxygen. Respiratory failure may be acute or chronic. Typically treated as a medical emergency, acute respiratory failure (ARF) occurs when fluid builds up in the air sacs in your lungs, which stops lungs from releasing oxygen into your blood. If not treated quickly, this condition in most cases may lead to death. With appropriate and timely treatment, the serious complications caused by acute respiratory failure can be reversed. Documentation is important to ensure appropriate care and accurate reimbursement, and medical coding outsourcing is an ideal option for physicians to simplify their documentation process.

Acute Respiratory Failure

Acute respiratory failure (ARF) is classified as hypoxemic (low arterial oxygen levels), hypercapnic (elevated levels of carbon dioxide gas), or a combination of the two. In most cases one or the other predominates. There are various causes associated with this respiratory condition which include – obstruction (like chronic obstructive pulmonary disease (COPD) or asthma), injury to the spinal cord, brain, ribs or chest (that affect breathing process), acute respiratory distress syndrome (ARDS), drug or alcohol abuse, toxic chemical inhalation, stroke and other infections of the lungs. When compared to chronic respiratory failure (which is an ongoing condition) the acute respiratory failure occurs suddenly and lasts for a short time.

Signs and Symptoms

In most cases, patients with ARF will experience some degree of respiratory difficulty. The common signs and symptoms of this condition will generally depend on its underlying causes and the levels of oxygen and carbon dioxide in your blood. Some of the most common signs and symptoms include –

  • Rapid breathing
  • Air hunger (feeling like you can’t get as much air as you need)
  • Sleepiness
  • Restlessness, confusion and anxiety
  • Rapid and shallow breathing
  • Racing heart
  • Profuse sweating
  • Loss of consciousness
  • Irregular heartbeats (arrhythmias)
  • Bluish coloration in the skin, fingertips, or lips
  • Inability to breathe

Persons with a family history of chronic (long-term) respiratory problems, who smoke tobacco products, drink alcohol excessively and who sustain an injury to the spine, brain, or chest may be at high risk of suffering this acute respiratory condition.

How to Diagnose and Document ARF

Acute respiratory failure is a condition that requires immediate medical condition. Therefore, patients must be supplied with oxygen that helps them to breathe normally, and prevents tissue death in the brain and other organs. Once the patient’s condition is stabilized, physicians may begin steps to fully diagnose the condition.

As part of initial diagnosis, physicians may conduct a detailed physical examination and evaluate your previous health history. They may also check your body’s oxygen and carbon dioxide levels with a pulse oximetry device and an arterial blood gas test. In addition, a chest X-ray will also be conducted to search for abnormalities in the lungs.

Treatment for this condition typically depends on the underlying conditions a person suffers from and may include pain medications or other medicines that help patients breathe better. In some cases, oxygen may be supplied from an oxygen tank if a patient can’t breathe adequately on their own. For patients who require prolonged ventilator support, an operation called tracheostomy (that creates an artificial airway in the windpipe) may be performed.

Pulmonary medical coding involves using the specific ICD-10 diagnosis codes for reporting acute respiratory failure (ARF) on the medical claims they submit to health insurers for reimbursement.

ICD-10 Codes to Use

J96 – Respiratory failure, not elsewhere classified

J96.0 – Acute respiratory failure

  • J96.00 – Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
  • J96.01 – Acute respiratory failure, with hypoxia
  • J96.02 – Acute respiratory failure, with hypercapnia

J96.2 – Acute and chronic respiratory failure

  • J96.20 – Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
  • J96.21 – Acute and chronic respiratory failure, with hypoxia
  • J96.22 – Acute and chronic respiratory failure, with hypercapnia

J96.9 – Respiratory failure, unspecified

  • J96.90 – Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
  • J96.91 – Respiratory failure, unspecified, with hypoxia
  • J96.92 – Respiratory failure, unspecified, with hypercapnia

Acute respiratory failure (ARF) is a condition that can cause long-term damage to the lungs and therefore it is important to seek medical care if you are experiencing any specific symptoms of this condition. Appropriate treatment helps in better lung function. People suffering from respiratory failure can also benefit from pulmonary rehabilitation, which includes exercise therapy, education, and counseling.

Medical coding for respiratory failure can be a challenging process. For correct and timely medical billing and claims submission, healthcare practices can outsource their medical coding tasks to a reliable and established medical billing and coding outsourcing company that provides the services of AAPC-certified coding specialists.

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