Q&A: Respiratory failure following surgery due to other underlying conditions

Q: On pages 139-140 of the 2016 CDI Pocket Guide, the guidance states that code J95.82 should not be assigned when post procedural respiratory failure is attributed by the provider to a preexisting or other underlying condition. It seems like this statement contradicts coding guidelines. Could you please clarify?

A: The statements about J95.82x and J96.xx are completely consistent with the ICD-10-CM tabular notes. There are mutually exclusive Excludes 1 notes for both codes, which direct you to use either set of codes. Therefore, until there is further official direction or advice, if the documentation clarifies that the post-procedural respiratory failure is due to another cause (such as COPD, heart failure, etc.), it can be coded as J96.xx, not the complication code.

In addition, our statements follow Section I.B.16 of the 2016 Official Guidelines for Coding and Reporting, which indicates a cause-and-effect relationship between the procedure and respiratory failure must be established before assigning the complication code:

Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.

Therefore, when a provider specifically documents that respiratory failure occurring after surgery is primarily due to a preexisting or other underlying cause than the procedure, ICD-10-CM tabular instructions and the Official Guidelines for Coding and Reporting prohibit assignment of code J95.82x. 

Following submission of this Q&A for publication, the new 2017 ICD-10-CM Official Guidelines for Coding and Reporting (OCG) were released by CMS making a small but important change to be considered in Section I.B.16 by modifying the first sentence with an additional terminal phrase:

“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification.”

The answer to the question is not changed by this provision because the classification still has the same mutual Excludes 1 note for postprocedural respiratory failure (J95.82x) and respiratory failure in other conditions (J96.xx). When respiratory failure that occurs following a procedure is specifically documented by the provider as due to another underlying or pre-existing condition, the classification excludes it from J95.82x.

Editor’s note: Richard D. Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, and author of the CDI Pocket Guide answered this question. Contact him at info@pinsonandtang.com.