Health Information Management

Respiratory failure code description limitations

JustCoding News: Inpatient, February 29, 2012

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by Robert S. Gold, MD

In March 2011, the ICD-9-CM Coordination and Maintenance Committee updated the following code definitions and exclusions:

  • 518.5: Pulmonary insufficiency following trauma and surgery
  • 518.51: Acute respiratory failure following trauma and surgery
    • Respiratory failure, not otherwise specified, following trauma and surgery
  • 518.52: Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery
    • Adult respiratory distress syndrome (ARDS)
    • Pulmonary insufficiency following surgery
    • Pulmonary insufficiency following trauma
    • Shock lung related to trauma and surgery
  • 518.53: Acute and chronic respiratory failure following trauma and surgery
    • Excludes: acute and chronic respiratory failure in other conditions (518.84)
  • 518.8: Other diseases of lung
  • 518.81: Acute respiratory failure
    • Excludes: acute respiratory failure following trauma and surgery (518.51)
  • 518.82: Other pulmonary insufficiency, not elsewhere classified
    • Excludes: acute interstitial pneumonitis (516.33) ARDS associated with trauma or surgery (518.52) pulmonary insufficiency following trauma or surgery (518.52)
  • 518.84: Acute and chronic respiratory failure
    • Excludes: acute and chronic respiratory failure following trauma

I'd like to discuss some of the limitations and challenges of these codes and their current descriptions.

Postoperative and post-traumatic respiratory failure

ICD-9-CM codes 518.5–518.53 include the description "following trauma and surgery." Combining trauma and surgery into one code is inappropriate. Patients with trauma, lung contusion, or bilateral traumatic pneumothoraces or hemothoraces will develop post-traumatic respiratory failure. The same is true for patients with crushed tracheas. These patients are distinctly different from those with postoperative respiratory failure. Each group should be tracked differently; therefore, they should be coded differently too.

Research is impeded by not coding and tracking each group separately. That's because even when a patient experiences trauma, surgery may be the actual cause of the postoperative respiratory failure. The POA indicator does not help clarify the cause of post-traumatic respiratory failure because respiratory failure may or may not exist on admission.

Coders should report postoperative respiratory failure only when problems with a surgical procedure lead to respiratory failure. However, they should not report it when the respiratory failure occurs in the following situations:

  • After an operation due to the reason for the surgery and not the surgery itself (e.g., when a bullet wound causes hemorrhage into the lung; the hemorrhage would occur regardless of whether the patient requires surgery)
  • Due to aspiration completely unrelated to the operation
  • Due to an ARDS event related to sepsis or pulmonary embolism that occurs after admission but prior to the induction of anesthesia
  • Due to events totally unrelated to the surgical operation (e.g., heart failure or acute exacerbation of chronic obstructive pulmonary disease)

Consider this scenario: Two days after surgery, a patient develops atrial fibrillation with rapid ventricular response, subsequent acute pulmonary edema, and acute respiratory failure. The patient is placed on a ventilator. Ideally, coders should assign code 518.81 rather than code 518.51 even when the respiratory failure occurs during the postoperative phase. However, without more accurate code definitions, the acute respiratory failure will be incorrectly classified as a complication of the surgical procedure.

Pulmonary insufficiency

ICD-9-CM codes 518.52 and 518.82 often confuse coders because a uniform definition of pulmonary insufficiency simply doesn't exist. This lack of a definition can lead to misinterpretation and even fraud. Some consultants advise coders to take advantage of these codes. This is wrong.

The terms "respiratory insufficiency" (regardless of whether it's postoperative) and "respiratory distress" are completely misused and misunderstood, which leads to incorrect coding. For example, coders often are seen to assign 518.82 for children who have mild asthma attacks when the documentation says "acute respiratory distress." They also assigned 518.5 (until the code changed) for patients who were purposely being weaned slowly from a ventilator after they undergo massive surgery and when documentation includes the term "postoperative respiratory insufficiency." The code definitions are inadequate, and this puts coders at risk for unethical and fraudulent conduct. The term "respiratory insufficiency" should not be referenced with any ICD-9 code. Codes already exist for atelectasis, pneumonia, tension pneumothorax, iatrogenic pneumothorax, and aspiration pneumonitis. They also exist for all permutations of events that can occur during the postoperative phase that can cause difficulty in clearing carbon dioxide from the lungs. None of these conditions constitute acute respiratory failure.

The code for respiratory insufficiency is misused and overused. I predict that the inappropriate assignment of this code will result in billions of dollars in overpayments and that the National Center for Health Statistics will eventually need to redefine it. Respiratory insufficiency is a useless concept. The intent of the code is to identify ARDS regardless of whether it progresses to acute respiratory failure, not to identify patients who experience pain when breathing due to an upper abdominal or chest incision and who benefit from pain medication and incentive spirometry.

Acute-on-chronic postoperative and post-traumatic respiratory failure don't exist. The cause of the acute condition is virtually never the same as the cause of the chronic condition. Physicians should document each condition and its etiology separately. This is why 585.x codes exist for chronic kidney disease and 584.x codes exist for acute renal failure. It's incorrect to combine acute and chronic respiratory failure into one code. Instead, codes should distinguish between patients with chronic respiratory failure (and its cause) who undergo surgery and patients who develop acute respiratory failure (and its cause) after surgery.

Don't let your hospital become fodder for recovery auditors by over-reporting conditions that patients don't have or for identifying conditions that do not meet the intent of the codes.

Editor's note: This article was published in the February issue of Briefings on Coding Compliance Strategies. Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician clinical documentation improvement programs. E-mail questions to him at

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