What are the documentation requirements for coding respiratory failure in Section I of the MDS?

Answer: The key to coding respiratory failure in Section I of the MDS is in the physician documentation. In order to code any diagnosis in this section of the MDS it must be supported by MD documentation during the previous 60 days and actively treated in the 7 day look back. Active Diagnosis Definition: A physician documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days that has a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death within the 7-day look back period.

To support active diagnosis it requires:

• Physician documented diagnosis in the 60-day look back period. 
• Documentation supporting active diagnosis in the 7-day look back period.
• Documentation related to necessary care, monitoring, interventions, symptoms, or risks relative to the diagnosis.
• Consistency with radiological reports, laboratory reports, positive study, test or procedures, physician orders, progress notes, interdisciplinary notes, treatment records, mood/behavior records and the current plan of care

The physician documentation may be similar to the following: “acute on chronic respiratory failure secondary to acute exacerbation of COPD”. In the absence of supportive physician documentation stating respiratory failure the diagnosis would not exist.

The supportive documentation guidelines for the MDS indicate the documentation should support the patient has respiratory failure, which is defined as condition in which not enough oxygen passes from the lungs into the blood. Respiratory failure also can occur if the lungs can’t properly remove carbon dioxide from the blood.

In addition to MDS coding in order to assign the correct ICD-10 code for this diagnosis, additional supportive documentation from the MD should also include the following:

• Chronicity (acute, chronic, acute on chronic),
• Specificity (with or without hypoxia and with or without hypercapnia)
• When post procedural indicate whether it is a complication or expected outcome 
• Document tobacco use