Q&A: Pneumonia versus acute respiratory failure as principal diagnosis

Q: If a patient is admitted with both gram-negative pneumonia and acute respiratory failure, which should be sequenced as the principal diagnosis?

A: This question often causes friction between both coders and CDI professionals. The confusion lies in the instructions found within American Hospital Association’s (AHA) Coding Clinic over the last 15-20 years as well as the use of the Official Guidelines of Coding and Reporting to “optimize” payment.

Years ago, the ICD system viewed acute respiratory failure as a symptom more so than a definitive diagnosis. As you are likely aware, Section 1.C.18.b in the Guidelines instruct us:

Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

The early Coding Clinics instructed coders to sequence the pneumonia first, ahead of the code for acute respiratory failure. Then the Guidelines switched to say the opposite (that we should sequence the respiratory failure first). This caused a rise in concern since many professionals saw respiratory failure as a symptom versus a definitive diagnosis and the final instruction stated that the circumstances of admission must be considered.

Coding Clinic, First Quarter 2008, p. 18, instructed us that when acute respiratory failure and aspiration or bacterial pneumonia were both present on admission, either could be sequenced as the principal diagnosis if both met the definition of a principal diagnosis.

The Guidelines (Section 1.C.10.b.1-3) say that acute respiratory failure will be sequenced differently according to the specific situation:

Selection of the principal diagnosis will be dependent on the circumstances of the admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations. If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

So, long story short, the answer depends on the encounter. Speaking for myself, I tend to sequence the acute respiratory failure first as this will always require an admission to the hospital where the pneumonia may not. The patient will be discharged home when the respiratory failure is resolved. The pneumonia will likely still be under treatment with antibiotics.

Many will argue that we will move to a higher paying DRG with the pneumonia sequenced first. That is true but I do not encourage the practice of sequencing based upon the level of reimbursement unless as Guidelines (Section 2.C) says (emphasis added):

In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

We need to closely review the record to determine if both diagnoses equally meet the criteria for principal diagnosis before making a sequencing decision.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.