Wiki Respiratory Failure

[brodel]

Is it ok to assume a diagnosis of respiratory failure when all the Dr. documents are the vent settings under his assessment and plan yet he does NOT document "respiratory failure"??

I don't feel this is an "ok" practice but I'm getting some mixed opinions. Any help would be appreciated.

 

[cordelia]

Definitely query Physician.

Cordelia, CCS, CPC

 

[cluke]

I would definately not code the respiratory failure if the provider did not state it him or herself. We as coders cannot infer this information.