Q&A: Primary diagnosis for multiple respiratory conditions

Q: If a patient is admitted with respiratory failure and chronic obstructive pulmonary disease (COPD) or asthma exacerbation (and other acute respiratory conditions), which diagnosis should be assigned as the primary diagnosis? Is there a specific rule that requires a “code first” note under the code grouping for acute respiratory failure? Or is there a better way to determine whether respiratory failure or another respiratory condition should be sequenced first?

Example patient #1: The patient was admitted for respiratory failure with hypoxia and acute asthma exacerbation. Treatment included oxygen therapy, steroid medication, and nebulizer treatments. In this case, would acute asthma exacerbation be assigned as the primary diagnosis?

A: Per the ICD-10-CM Official Coding Guidelines for Coding and Reporting for admissions, it is important to consider the circumstances of the admission and focus of treatment when selecting the principal diagnosis. In the first example you gave, the patient was admitted with respiratory failure and another acute condition, so the determination would need to be made by asking, “What was the focus of treatment and resources used for each acute condition?” If the documentation is not clear as to whether acute respiratory failure and asthma are equally responsible for occasioning the admission, query the provider for clarification.

When selecting respiratory failure as a principal diagnosis, of course it is good to see treatment such as intubation, high flow nasal cannula, non-rebreather, and change in level of care in the documentation. Also, if you have enough information, consider querying for the specificity of the patient’s asthma diagnosis. 

For help with sequencing, you can reference the following statement from the. ICD-9-CM Official Guidelines for Coding and Reporting: “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.”

Q: Example patient #2: The patient presented with an asthma exacerbation. According to the physician’s note, “The etiology of the exacerbation is likely due to a [upper respiratory infection] URI (isolation of rhinovirus).” The patient was initially treated with doxycycline and ceftriaxone for community-acquired pneumonia coverage, but antibiotics were discontinued as the most likely cause of the asthma exacerbation was related to rhinovirus (the physician ruled out pneumonia).

The physician also documented, “[Respiratory Virus Panel] tested positive for rhinovirus–most likely accounting for the asthma exacerbation.” The patient received treatment for both asthma and the infection. Which diagnosis should be assigned as the principal diagnosis: asthma exacerbation or rhinovirus infection?

A: The asthma exacerbation would be coded first per the official coding guidelines and the rhinovirus would be coded as a secondary diagnosis.

Editor’s note: Nicole Nodal-Rodriguez, MSN, RN, CCDS, CDI education specialist at HCPro, answered this question. Contact her at Nicole.Nodal-Rodriguez@hcpro.com.