Cachexia
Questions for the group; a record documents "patient appears cachectic".
Physical exam notes muscle wasting and scaphoid abdomen. Patient has
documented unintentional weight loss of > 10% of body weight over 3
months. There is no documentation of malnutrition. Patient has multiple
comorbidities, including COPD, ESRD on hemodialysis, chronic systolic
HF, mechanical mitral valve.
* With the existing documentation, would you code cachexia?
* Would you query for a malnutrition diagnosis? If so, which
one?
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org
Physical exam notes muscle wasting and scaphoid abdomen. Patient has
documented unintentional weight loss of > 10% of body weight over 3
months. There is no documentation of malnutrition. Patient has multiple
comorbidities, including COPD, ESRD on hemodialysis, chronic systolic
HF, mechanical mitral valve.
* With the existing documentation, would you code cachexia?
* Would you query for a malnutrition diagnosis? If so, which
one?
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org
Comments
symptoms and ask if they are clinically significant, and if so can a
diagnosis be provided. I wouldn't query for malnutrition unless it was
already documented by a dietician or the provider. It may be considered
leading otherwise, but that's me.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"Patriotism is easy to understand in America; it means looking out for
yourself by looking out for your country" Calvin Coolidge
mention that. I meant no malnutrition diagnosis is documented by the
"practitioner".
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org
dieticians documentation, ask if their assessment is clinically
significant and if so can they provide a diagnosis and the level of
severity (mild, moderate, severe, unable to determine, other). The query
form we have has the adult malnutrition guidelines on them so the
provider knows what moderate and severe means. Of course I'm lucky that
my dieticians document "moderate to severe" or "mild" nutritional risk
and then the stage of the nutritional injury. All of which I include in
my query.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"Patriotism is easy to understand in America; it means looking out for
yourself by looking out for your country" Calvin Coolidge
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org
Robert
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"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
Paula Rector, RHIT, CCDS
cachexia with:______ if you pick malnutrition, severe, protein calorie codes for both come up with no exclusions listed.
The coding guidelines in the ICD-9 book say "additional signs and symptoms that may not be associated routinely with a disease process should be coded when present."
So the question is: who makes the determination of whether the sign/symptom is routinely associated with a disease process? I have gone round and round with cholecystitis and jaundice. Some coders feel very strongly that jaundice is routinely associated with gallbladder disease and all liver diseases.
I will be interested to see what others have to say.
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
We have never heard that information before. You can have someone who is malnourished, but not cachectic- for example the pt who eats junk food all day or has a malabsorption disease . We code both from a CDI and a coding perspective.
When you enter cachexia, the encoder does ask if it is associated with malnutrition. If you select any of the malnutritions, it still codes both.
I could not find any coding clinic that excludes the cachexia.
Thanks,
Linda
Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org
1. The coding of severe forms of malnutrition has been controversial - there have been providers in the State of California that have reported 262 and 261 at higher levels that would be expected, and this has raised questions from 3rd parties.
2. The 'new' query practice brief issued by AHIMA and ACDIS imposes a duty upon CDI and Coding Professionals to 'vet' key diagnostic terms.
AHA Coding Clinic for ICD-9-CM, 1Q 2013, Volume 30, Number 1, Pages 3-17
Question:
Can we report the code for emaciation (code 261), if the physician only documents emaciated? Some
coders do not feel that it is appropriate to report code 261, Nutritional marasmus, for the diagnosis
of emaciated, since there is no specific index entry for emaciated. Other coders feel that “emaciation”
and “emaciated” are the same conditions, and therefore, code 261 is appropriate for the diagnosis of
emaciated. This code assignment can be located under:
Emaciation (due to malnutrition) 261
Answer:
No, it is not correct to assign code 261, Nutritional marasmus, if the physician only documents
emaciated or emaciation without the documentation of “malnutrition.” Assign code 799.4, Cachexia,
for a diagnosis of emaciated/emaciation. If the provider intended to describe malnutrition, then it
should be documented as such. Marasmus is a type of protein-energy malnutrition that is caused by
a severe calorie deficiency, mostly occurring in young children. Whereas, emaciated is a descriptive
term, meaning unusually thin due to wasting. Although the Index currently refers to code 261, a
basic rule of coding is that further research is done if the title of the code suggested by the Index
does not identify the condition correctly. Because of the code-set freeze in effect, and the limited
time in which ICD-9-CMwill remain, no revisions can be made to the Index entry for emaciation.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Conditions documented may include symptoms which are an integral part of the
disease process and should NOT be coded. HOWEVER, certain symptoms
represent important problems in medical care and it might be desirable to
classify them in addition to the known cause IF the condition is
specifically addressed, either by additional diagnostic studies or
therapeutic procedures, then an additional diagnosis code may be added. So
if you can show the coder the additional resources or significance they
might be more willing to report it. Also, it would really be good if you
could get the additional documentation in the record stated as such but that
might be harder to do to get the physician to provide that level of
specificity. Hope this helps you..................
Debra Beisel Denton, RHIA, CCS, CCDS
Just from a clinical standpoint, I would argue that cachexia is not inherent at all in protein calorie malnutrition. Most of our patients with protein calorie malnutrition (even severe) in this country probably still have BMI's that are >18.The American dietetic association (? I hope that’s right). Does not say that a patient must be underweight to qualify as having malnutrition. For this reason I do not think Cachexia is 'inherent' to malnutrition.
I would may feel differently if we were talking about other types of malnutrition like Kwashiorkor however I do not know of any guidance that states you cannot code these two dx together.
In the ICD-9 book under 'Cachexia' 799.4, it states 'Tip: assign an additional code for any associated malnutrition, if documented'.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Cachexia 799.4 when the physical exam is only saying "cachexic appearing".
Do you feel that is the same thing?
Deb
One could ask for the clinical significance of the cachexia.
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
If you have the 3M Encoder, here is a good way to view this one: type cachexia, then "due to malnutrition"... you actually get 7994, cachexia. ") If you specify the malnutrition as due to "other circumstance"...then choose the severity of the malnutrition (any), you get both codes!!= malnutrition and cachexia.
My thought on the jaundice code... if jaundice was integral to all liver conditions and all chole issues... we wouldn't need the code for jaundice on the adult side. When jaundice appears, you usually have a higher severity of illness because the underlying condition has progress past the point of an ordinary case of gallstones or cirrhosis-likely end organ failure. Your system can't filter out the waste.... so it stores it... in your skin, sclera, etc. I had a patient once when I was a case manager that was the color of a school bus! He said he was hoping Crayola would name a new crayon color after him. Sweet man... he passed away not long after I had the honor of meeting him.
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Cone Health at Alamance Regional
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com