Malnourished vs malnutrition

willarl@ah.orgwillarl@ah.org
in Clinical & Coding
The doctor documented malnourished and the coder coded it as unspecified protein calorie malnutrition. Malnourished seems to be a symptom rather than a diagnosis. What are your thoughts on this?
Thank you!

Comments

  • proddy@clarionhospital.orgproddy@clarionhospital.org
    I would not have coded it as malnutrition.  If there were adequate clinical indicators and data present, consider a query?  We are in the process of re-defining Malnutrition criteria and documentation needs (in collaboration with the hospital nutritionist) to more accurately capture the severity of malnutrition.
  • ybattaglia@stanfordhealthcare.orgybattaglia@stanfordhealthcare.org

    RAC audits frequently target malnutrition.  Denials are based on a lack of  supporting documentation. To use malnutrition, the dietitian's assessment needs to be in place, as well as clear documentation about malnutrition.

  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
    lissettewillard@yahoo.com said:
    The doctor documented malnourished and the coder coded it as unspecified protein calorie malnutrition. Malnourished seems to be a symptom rather than a diagnosis. What are your thoughts on this?
    Thank you!


    You are on target here...malnourished, cachectic, etc... are descriptors and not diagnoses. The MD's documentation that the patient is malnourished with the dieticians assessment, BMI, and other pertinent findings from the chart best support the diagnosis of malnutrition.

    Jeff

  • proddy@clarionhospital.orgproddy@clarionhospital.org
    If the dietitian used the term malnutrition, would you query then based on that assessment finding along with the documentation of malnourished and/or cachectic?
  • jackietouch@aol.comjackietouch@aol.com
    Yes, definitely query citing the clinical indicators that are in the RD assessment (appearance, BMI, weight loss, etc.) and any risk factors/treatment. 

    Jackie Touch, MSN, RN, CCM
    CHOC Children's, Orange, CA
  • willarl@ah.orgwillarl@ah.org
    The doctor documented malnourished and the coder coded it as unspecified protein calorie malnutrition. Malnourished seems to be a symptom rather than a diagnosis. What are your thoughts on this?
    Thank you!

  • willarl@ah.orgwillarl@ah.org
    Thank you all for taking your time to answer my question. I truly appreciate it.
    Sincerely,
    Lissette
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