Ask Proactive – When should I code respiratory failure in Section I of the MDS?

When should I code respiratory failure in Section I of the MDS?

A:

To code any active diagnose in Section I, RAI manual requirements must be met including MD documented diagnosis in the last 60 days & supporting documentation that the diagnosis is active in the 7-day reference period. The physician may exactly document that respiratory failure a condition is active.  Also, chronic respiratory failure or a recent, new episode or acute exacerbation of respiratory failure shown by tests, symptoms or signs of respiratory decompensation or continuing therapy with medications or other interventions to manage this condition may support active diagnosis.

Acute or chronic respiratory failure happens with decompensation of gas exchange between the lungs and the blood resulting in hypoxia. Diagnostic tests may include chest X-ray, pulse oximetry readings, arterial blood gases, lung function tests, etc.  Depending on the cause of respiratory failure, symptoms may be drowsiness, shortness of breath, anxiety, confusion, tachypnea, headache, extreme fatigue, or arrhythmias, etc.  Therapies may include supplemental oxygen or inhaled or oral medications (Stratton, 2021).

Resources:

• Center for Medicare and Medicaid Services. (2019, October). MDS 3.0 RAI Manual, I-7- I-15.  Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html 
• Stratton, S.  (2021, March 23).  Acute Respiratory Failure. BMJ (British Medical Journal) Best Practice.  https://bestpractice.bmj.com/topics/en-us/853