by Richard D. Pinson, MD, FACP, CCS
The diagnosis and documentation of respiratory failure continues to be challenging for coders, documentation specialists, and physicians. Many physicians, including pulmonologists, are unaware of the current clinical standards for diagnosing acute respiratory failure and commonly overlook the presence of chronic respiratory failure.
Yet they typically identify multiple clinical criteria and provide appropriate management for respiratory failure, which creates query opportunities. In this article, we will discuss a variety of clinical indicators for respiratory failure and identify a number of common documentation improvement opportunities.