cachectic vs cachexia

annnd2009@gmail.com

In a different facility whether this needed to be queried was a source of disagreement. We were told by a consulting company that the two were not interchangable one was a diagnosis and one was a symptom/descriptor...has anyone had issue with this?

I guess it should not be and issue and they are considered interchangeable since the 3M CAC (360) takes you there automatically.

If anyone thinks there could be a potential issue with this please comment.

Thank you,
Ann Donnelly
ann.donnelly@exempla.org

Linda_Rhodes

Hi Ann,
Our coders follow the same thought process. They will not take cachectic (they say it is a descriptor and not a diagnosis). We had to teach our providers to include cachexia as a diagnosis in order to be captured.

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

lindenbm@bellsouth.net

Ann,
Our coders do the same. They will only code "cachexia" if stated and not cachectic or looks cachectic.
Mary Lindenboom, RN, BSN, CCDS
Clinical Documentation Manager
Flagler Hospital
400 Health Park Blvd.
St. Augustine, FL 32086
(904) 819-4254

vdavis2

We actually won an insurance appeal on a similar issue. The MD documented "severely malnourished" instead of "severe malnutrition". Our coder coded it as the mcc and it was the only mcc. The insurance auditor wanted to remove the mcc; we fought it using general dictionary definitions and supportive clinical data from the record!
Big win for us!-Vicki
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

evanspx@sutterhealth.org

I am glad you won the appeal. However, it is almost a crime the insurance auditor advocated removal - surely any reasonable person would consider severely and severe have the same intent and meaning.

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

katysuegood@gmail.com

Go Vicki!

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

ssalinas

Was the issue malnourished vs. malnutrition, or severe vs. severely? I assumed it was the term 'malnourished'.
If that was the case, very good for you guys!
Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org

judithbates

High fives all around!!!
I really support standing behind the documentation and yes, if Mr Webster can help...So be it!!!
Let this be an inspiration to us all that the big name auditors shall not have the last word. When you think of all the cases that are not worth fighting, the money will be adding up.
Thanks so much for sharing Vicki!!!

Judi Bates RN, BSN, CCDS
Our Lady of Lourdes Medical Center
CDI Specialist
856-757-3161
Beeper 66x2906

annnd2009@gmail.com

I guess it's not an entirely settled issue... probably the best approach would be for individual facilites decide whether to premeptively week teh verbage to avoid an audit or be willing to fight it and hope they are as successful as Vicky.

I just found it odd that 3m Computer Assisted Charting would take you there automatically.

There is not agreement amongst the people I have asked. How long did your appeal process take?

Did it change any processes to prevent going through it in the future, or do you think that win will prevent them from ever questioning.

Are audits/appeals public? Can they be used like court cases,citing previous results as defense?

Thanks for all the input!
Ann

vdavis2

Wow, this topic spawned a good deal of discussion! I agree with Paul, the auditor should be ashamed! The issue dealt with the exact term being documented as "malnourished" instead of "malnutrition." The denial stated, "based on the basic definition of malnutrition the auditor could not find physician documentation of malnutrition, nor clinical evidence to support the diagnosis." We were shocked that a professional denied the ability to report a condition based on the BASIC DEFINITION of the word. Since appeals are many times won by refuting the language or the rationale used by the auditor in the body of the denial, we just had to look up the basic definitions! (Probably one of the shortest appeals we've written- and yes, it was hard not to include a little sarcasm in our appeal letter! J )
According to Webster, we went from a noun to an adjective!!!
Malnutrition: noun meaning: poor nutrition caused by an insufficient, over sufficient, or poorly balanced diet or by a medical condition.
Malnourished: adjective meaning: poorly or improperly nourished; suffering from Malnutrition: thin, malnourished.
Ex: malnourished victims of famine
J- VICKI

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

evanspx@sutterhealth.org

I am glad you appealed and won as I believe it is important that any/all of us dealing with coding, documentation and compliance should issue an appeal if or when have a valid and compliant reason for doing so.
Thank you for your insight on this matter.

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