Malnutrition
We are having difficulty getting our Coders to accept SPCM. When asked what criteria they need to see to be able to capture this , it always changes with each Coder. Our Registered Dieticians have received specialized training and are excellent in describing "muscle wasting, decreased caloric needs, etc" and always include their Plan of Care. We have had several group meetings with the Coders to be able to accurately instruct the physicians on the appropriate documentation, and still one Coder will accept it and another will not. The physicians are becoming disgruntled at the constant redirecting. One time it will only need to be documented by the Hospitalist, the next time all consulting physicians must include it. Would you please tell us exactly what must be documented and by whom to help assuage the concerns of the Coders for a RAC audit. Thank you