Pulmonary Edema and Respiratory Failure


MS-DRG	CMS DRG (Prior to 10/1/2007)
189	Pulmonary Edema and Respiratory Failure	087	Pulmonary Edema and Respiratory Failure

Pulmonary Edema

Pulmonary edema refers to a pathologic state in which there is excessive, diffuse accumulation of fluid in the tissues and alveolar spaces of the lung. It is broadly divided into cardiac and noncardiac origin.

Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding. Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged frothy sputum. Diagnosis is clinical and by chest x-ray. Treatment is with O2, IV nitrates, diuretics, morphine, and sometimes - endotracheal intubation and mechanical ventilation.

Respiratory failure is the inability of the respiratory system to supply adequate oxygen to maintain metabolism and to eliminate carbon dioxide.

Causes of respiratory failure: Alveolar hyperventilation in normal lungs related to drug overdose, injury to small capillary, smoke inhalation, near drowning, pesticides and ARDS, chronic obstructive lung disease, and chronic intrinsic restrictive lung disease (CIRLD).

Common Signs/Symptoms

Anxiety
Confusion
Cough producing blood-tinged sputum
Cyanosis
Diaphoresis
Dyspnea
Headache
Hypertension may indicate significant cardiac reserve
Hypotension
Marked wheezing (cardiac asthma) may occur
Noisy respiratory efforts often make cardiac auscultation difficult; a summation gallop-merger of 3rd (S3) and 4th (S4) heart sounds - may be present.
Pallor
Restlessness
Tachycardia
Tachypnea

Principal Diagnosis Codes That Commonly Group To Drg 189

506.1 - Acute pulmonary edema due to fumes and vapors

514 - Pulmonary congestion and hypostasis

518.4 - Unspecified acute edema of lung

518.5 - Pulmonary insufficiency following trauma and surgery

518.81 - Acute respiratory failure

518.83 - Chronic respiratory failure

518.83.1 - Acute and chronic respiratory failure

Documentation to Support a Diagnosis of Respiratory Failure or Pulmonary Edema

When reviewing a principal diagnosis of respiratory failure, determine the underlying cause of the respiratory failure and follow the appropriate coding guidelines. Effective with April 20, 2005 discharges, there are not separate respiratory failure guidelines for respiratory and nonrespiratory causes. It is important to know the sequencing guidelines for respiratory failure, as well as the chapter-specific coding guidelines (obstetrics, poisoning, HIV, newborn) that provide sequencing direction.
When reviewing a principal diagnosis of pulmonary edema, coded 514, determine if there is a question about whether or not it is acute. If it is possibly acute, it needs physician clarification.
When reviewing a principal diagnosis of acute pulmonary edema, coded 518.4, determine if there is any mention of heart disease or failure, if it was due to an external agent, or if it was of noncardiac origin. Then follow the appropriate coding conventions and guidelines.

Coding Guidelines

Hypostatic pneumonia

Assign code 514, pulmonary congestion and hypostasis, for hypostatic pneumonia. If the physician has documented hypostatic pneumonia without any further information, then code 514 is the correct code assignment. If the physician indicates that the patient has bacterial pneumonia, then the physician should document it as such and a code should be assigned based on the type of pneumonia. (See Coding Clinic, second quarter 1998, pages 6 and 7.)

Acute pulmonary edema/heart disease

Acute pulmonary edema with mention of heart disease or failure codes to 428.1, per the ICD-9-CM, volume 2, Tabular List, see excludes note under code 518.4.

Acute pulmonary edema due to adult respiratory distress syndrome associated with conditions not classifiable to code 518.5 is assigned to codes 518.4 plus 518.82, such as that with shock of any etiology excluding that in 518.5.

Postoperative pulmonary edema

Postoperative pulmonary edema NOS (without adult respiratory distress syndrome) is assigned to code 518.4, unless the pulmonary edema is stated to be due to left ventricular failure (428.1) or congestive heart failure (428.0).

Postoperative pulmonary edema due to fluid over-load is coded 518.4 and 276.6.

Postoperative pulmonary edema with adult respiratory distress syndrome is assigned to 518.5. Conditions assigned to code 518.5 include that with pulmonary edema.

Adult respiratory distress syndrome (ARDS)

Acute pulmonary edema associated with ARDS is noncardiogenic.

ARDS due to conditions not classifiable to code 518.5 is coded to 518.82, other pulmonary insufficiency, not elsewhere classifiable.

ARDS following shock, surgery or trauma is coded to 518.5, pulmonary insufficiency following trauma and surgery. (See Coding Clinic, third quarter 1988, pages 7-9.)

Respiratory failure

Respiratory failure is classified as acute respiratory failure (518.81), chronic respiratory failure (518.83), acute and chronic respiratory failure (518.84), and respiratory failure following surgery or trauma. (See Coding Clinic, fourth quarter 1998, page 41).

Chronic myasthenia gravis with acute exacerbation/respiratory failure

A patient with chronic myasthenia gravis goes into an acute exacerbation and is admitted to hospital due to acute respiratory failure. Principal diagnosis is acute respiratory failure, coded 518.81. Secondary diagnosis is myasthenia gravis with acute exacerbation, coded 358.01.

Acute respiratory failure may be designated as principal diagnosis if it led to the hospital admission, or it may be listed as an associated condition if it occurs after admission. This applies to respiratory failure resulting from either a respiratory or nonrespiratory condition, unless the Index or Tabular List instructs otherwise. (See Coding Clinic, first quarter 2005, page 4, and fourth quarter 2004, page 139.)

Congestive heart failure/respiratory failure

When a patient was admitted in respiratory failure due to and/or associated with CHF, the CHF was the principal diagnosis until discharges of April 20, 2005 when the respiratory failure guidelines were revised.

A patient with congestive heart failure (CHF) is admitted to the hospital for acute respiratory failure. The principal diagnosis is acute respiratory failure, coded 518.81, and the secondary diagnosis is CHF, coded 428.0. The principal diagnosis depends on the reason for admission. Query the physician if the documentation is unclear. (See Coding Clinic, first quarter 2005, page 5, and second quarter 1991, pages 3 and 4.)

Emphysema/respiratory failure

A patient with emphysema is admitted to hospital for acute respiratory failure. The principal diagnosis is acute respiratory failure, coded 518.81. (See Coding Clinic, first quarter 2005, page 4.)

Impending respiratory failure

Impending respiratory failure is not coded. A threat of respiratory failure may exist, but respiratory failure would not be coded unless it occurs. (See Coding Clinic, second quarter 2002, page 6.)

Intubation/mechanical ventilation/respiratory failure

Absence of intubation and mechanical ventilation does not preclude the use of a diagnosis of respiratory failure, 518.8x. (See Coding Clinic, third quarter 1988, page 7.)

Noncardiac acute pulmonary edema

There are many diverse causes of noncardiac acute pulmonary edema, for example:

Postoperative pulmonary edema due to fluid overload is coded 518.4 and 276.6.
Postoperative pulmonary edema with adult respiratory distress syndrome is coded 518.5.
Neurogenic acute pulmonary edema in patients with central nervous system disorders is coded 518.4, unless there is mention of left ventricular failure (428.1).
Acute pulmonary edema due to smoke inhalation from a fire is coded 506.1 plus the appropriate E-code. (See Coding Clinic, third quarter 1988, pages 3 and 4) .

Overdosing on crack/respiratory failure

A patient is found to be in respiratory failure after overdosing on crack and is placed on a ventilator. This is considered a poisoning. The principal diagnosis was coded 968.5, poisoning by other central nervous system depressants and anesthetics, surface topical and infiltration anesthetics, until 10/1/02, when code 970.8, poisoning by other specified central nervous system stimulant, was created; plus 305.60, nondependent abuse of drugs, cocaine abuse, unspecified; and code 518.81, respiratory failure. (See Coding Clinic, first quarter 1993, page 25.)

A patient who overdosed on crack was admitted to the hospital with acute respiratory failure. The principal diagnosis is 970.8, poisoning by other specified central nervous system stimulant. The secondary diagnoses are 518.81, acute respiratory failure, and 305.60, nondependent abuse of drugs, cocaine abuse, unspecified. The poisoning is sequenced first because there is a chapter-specific guideline that provides sequencing directions specifying that the poisoning code is sequenced first followed by a code for the manifestation. (See Coding Clinic, first quarter 2005, pages 6 and 7.)