Q&A: Deciding whether acute respiratory failure or pneumonia should be principal

Q: If the acute respiratory failure is due to pneumonia and the respiratory failure resolves rather quickly, but the patient remains in the hospital for treatment of pneumonia, shouldn’t pneumonia be sequenced as the principal diagnosis? The basis of this question is not solely about reimbursement, but about the underlying cause. 

A: There’s no right answer here, unfortunately. We choose the principal diagnosis based on what occasioned the admission. Depending on your experience, the culture within your organization etc., these cases could be sequenced differently. Not having the complete medical record of a particular patient in front of me, I can only share from my personal experience.

I tend to sequence the respiratory failure first as no physician would typically send home a patient in respiratory failure. There is no coding direction that tells us we must first sequence the underlying cause. Unless, of course, the diagnosis is part of an etiology/manifestation pair. Acute respiratory failure is not part of an etiology manifestation pair; there is no note below respiratory failure that tells us that we must “first code the etiology.”

Respiratory failure often appears to “resolve” quickly, but such documentation doesn’t tell the whole story. If we stopped the treatment (oxygen, breathing treatments, continuous positive airway pressure [CPAP], or ventilation), the patient would likely reenter failure rather quickly.

The treatment plan in this case appears to focus on the pneumonia, as if we do not resolve the infectious process the respiratory failure would still remain an issue. In essence, we treat pneumonia in order to treat the respiratory failure.

The question that then arises is, if it were only pneumonia, and there was no respiratory failure would the patient require the inpatient admission? Would the patient require the close monitoring, ventilator support, oxygen application?

In most cases pneumonia can be treated in the outpatient arena with antibiotics and perhaps respiratory treatment. We need to ensure we sequence the diagnosis that “occasioned the admission.” If we did not work to correct the failure, the patient would die, for these reasons, I tend to sequence the respiratory failure first.

My best advice here is to query the provider (if the record’s not clear) as to which diagnosis led to the admission.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.