Ask Proactive – A resident was admitted with a diagnosis of acute on chronic respiratory failure requiring a new tracheostomy. The trach was placed during the hospital stay and the resident continues to require suctioning, respiratory monitoring, and oxygen therapy here in the SNF. Would we use the respiratory failure or presence of tracheostomy as the primary diagnosis?

Q:

A resident was admitted with a diagnosis of acute on chronic respiratory failure requiring a new tracheostomy. The trach was placed during the hospital stay and the resident continues to require suctioning, respiratory monitoring, and oxygen therapy here in the SNF. Would we use the respiratory failure or presence of tracheostomy as the primary diagnosis?

In this situation, the resident’s acute on chronic respiratory failure is the medical condition primarily responsible for the skilled care being provided.

The correct ICD-10 code for the primary diagnosis (I0020B) would be:

Primary Diagnosis:

• • J96.21 – Acute and chronic respiratory failure with hypoxia
    • (Use J96.20 if unspecified or J96.22 if with hypercapnia, based on provider documentation.)

Secondary Diagnoses:

• • Z93.0 – Tracheostomy status, to reflect the resident’s current trach care needs
  • Z99.81 – Dependence on supplemental oxygen, if continuous oxygen is in use

Important to note:

• • Z93.0 is a status code and cannot be used as a primary diagnosis. When submitted as primary, it will be returned to provider because it does not represent an active medical condition. It must be paired with the underlying condition (e.g., respiratory failure) that justifies the tracheostomy and the skilled care provided.

Correct diagnosis coding not only supports skilled coverage but also aligns with F695 regulations, which require facilities to provide and document appropriate respiratory services. Accurate ICD-10 coding reflects the acuity of your resident population, supports correct, and helps mitigate compliance risks.

To support accurate coding and skilled coverage, documentation should consistently show:

• • Respiratory assessments and monitoring
  • Suctioning frequency and response
  • Tracheostomy site care
  • Oxygen use and flow rate
  • Physician oversight and progress notes
  • Updates to the care plan

Next Steps:

Access Proactive’s virtual ICD.10 Coding for Skilled Nursing Workshop—to master ICD.10 coding with a focus on PDPM. This practical, easy to follow course is designed for busy SNF team members, with 5 self-paced modules broken down into 12 lessons for only $299.

Written By:

Jessica Miller, RN, RAC-CT

MDS Consultant

Proactive LTC Consulting