A patient presents to the Emergency Department (ED) due to an overdose of Ambien and is intubated and placed on mechanical ventilation. The attending physician admits the patient to the intensive care unit (ICU) and documents that the patient was intubated for airway protection because of the drug overdose. There was no documentation of respiratory failure and the patient was weaned from the ventilator the following next day. Can the coder assume that the patient was in respiratory failure and report code 518.81, Acute respiratory failure, based on the fact that the patient was intubated and placed on mechanical ventilation for airway protection?
Do not assign code 518.81, Acute respiratory failure, simply because the patient was intubated and received ventilatory assistance. Documentation of intubation and mechanical ventilation is not enough to support assignment of a code for respiratory failure. The condition being treated (e.g., respiratory failure) needs to be clearly documented by the provider.