specificity from dietician note

fentona@bronsonhg.orgfentona@bronsonhg.org
in CDI Talk Archive
Quick ?....If a physician write pressure ulcer coccyx and nursing writes stage 3 that can be used in coding. So my question is if a physician writes protein calorie malnutrition and the dietician consult states severe malnutrition r/t inadequate protein/energy intake. Can we code severe protein calorie malnutrition?
Thanks,
Amy

Amy Fenton, R.N.
Clinical Documentation Specialist
Bronson Hospital
Quality and Safety
601 John Street
Box 59
Kalamazoo, MI 49007
Phone 269-341-8442
Fax 269-341-8330
fentona@bronsonhg.org

Comments

  • Unknown
    edited April 2016
    No...Doc has to agree with the severity, in this case 'severe'

  • jrileyjriley
    edited April 2016
    Wouldn't that be nice! No, per official coding guidelines, we can pull the BMI from a dietitian's or nurse's note but not severity of the malnutrition.

    Below is excerpted from the official guidelines:

    "Documentation for BMI and Pressure Ulcer Stages


    For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages). However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient's provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.



    The BMI and pressure ulcer stage codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses)."



    Judy

    Judy Riley, RHIT, CCS, CPC
    Coding/CDI Manager, LRGHealthcare
    Lakes x 3315


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