Emaciation

cbarnes

I was recently advised that nutritional marasmus was a condition that normally occurred in third world countries and there were strict coding guidelines for this diagnosis. The coder didn't code the emaciation and when I questioned it that was the response I recieved from the coding supervisor.

I don't disagree w/ this but I cover an oncology floor and see emaciation written frequently by the physicians. In fact, it was written in this particular patients' H&P. The patients' BMI was 15.2 w/ a height of 5'2" and a weight of 82.9 #'s. There was also a dieticians' note on the chart w/ her assessment and recommendations w/ teaching for the patient.

When I put emaciation in our coding guide it shows up w/the description of nutritional marasmus.

I am @ a loss as to what to do.....any advice I can get would be helpful. I am going to discuss @ task force but was wondering if I was wrong ?

Thanks Charlene

NormaB

I've not heard anything advising us not to code emaciation. If anything we are always on the look out for severe malnutrition (or emaciation) when we are reviewing. We've never been dicouraged to not code emaciation.

Our coders would code it as well.

NBrunson,RHIA, CCDS

cbarnes

Thank You N.Brunson

I would like to hear from other places, also, when you have time. I would like to take the responses to task force w/ other research I have. I want to share w/ our coders what other hospitals are doing. Once again, thank you. Charlene

robert.hodges2

Perhaps a meeting with nutrition, an oncologist and coding would help. Sometimes bringing in clinical experts for education help standardized definitions and will certainly improve communication. I agree with your definition and actually see it written on occasion also, but haven't had the same issue with my coders.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

jolene.file

Hi Charlene!

I believe the reason that the coders are reluctant to code this diagnosis is because in

digardsk

I dieticians will designate marasmus on those very severe patients.

NormaB

In light of today's CDI Strategies Q&A article regarding Malnutrition, I must say I'm a bit confused. Seems the answer also supported the OP's coder collegues.

I suppose the best preventative answer is to query the severity of "emmaciation" using the Malnutrition guidelines of Mild or Moderate.

I think I will clarify w/both our CDI Consultant and our Coding Consultant just to be sure.

Norma T.Brunson, RHIA, CCDS

dvitalone1

Funny you should bring this up. I just found out that the coding supervisor here has told the coders not to query for malnutrition unless the physician has actually documented "malnutrition." Our dietary department documents on every patient wt loss, appetite, bmi, ht, wt, alb and all other pertinent labs then documents the appropriate type of malnutrition based on their findings and recommends type of nutritional supplement. I look to see if md documents any signs or symptom such as wt loss, cachexia, loss of appetite, etc then I will query for type of malnutrition stating dietary's documentation and explain to physician what dietician's recommendations are. I have recently found out that a MD signed a query for severe protein calorie malnutrition (our queries are part of the permanent record) but it was was not coded due to no md documentation of malnutrition in progress note even though dietary notes stated it. I understand that coders cannot code from the dietary notes that is why I queried the physician. Any thoughts?

Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist

david.smith

Maybe there is a policy and procedure issue. I would think that a query signed by the physician confirming the dx of severe protein-calorie malnutrition would be sufficient to code it given the fact that your query form is part of the permanent medical record. The only thing that I can think of to prevent this being used by coding is a policy that excludes the coding of a dx which is not documented in the progress notes, HP, consults, DC summary. Just a thought. I would question the reasoning for making the query part of the record if the documentation contained therein can't be used. I know best practice would promote the concurrent documentation in the PNs but that is not always achieved. Someone may need to address what can be used as source documents when coding the record.

dvitalone1

Thank you David.
I have been told the reasoning is the RAC but none of our charts have been audited for malnutrition as a MCC, I really think they are starting to become over cautious


Dawn M. Vitalone, RN

david.smith

Yeah, the RACs have everyone on the edge, but we also need to accurately reflect the patient severity. It sounds like there needs to be a discussion in-house re: information contained on your query and how it should/can be utilized by coding. We are kicking around the idea of a nutrition form that would contain all the elements that you had mentioned and then have a physician signature line (Note: our query form is not part of the permanent record). There are going to be RAC audits one way or the other, as long as there are clinical indicators and supporting documentation "in the record" then I would feel comfortable defending the coding when/if it were revised by a RAC.

cbarnes

We think our coders are becoming overly cautious, also, and our defense has been " if the clinical indicators and tx are present and the physician documentation supports the dx go w/ it." The coders response is we have the final word and it's our license @ risk. It's become a constant battle. After 11 years, it seems all the progress we made has vanished. Plus, we have a coding supervisor that is very negative about our clinical role. She has only been w/ the team 4 years and her choice would be for us to disappear. RAC really has her on edge. It seems many of us are facing the same obstacles. Charlene

dvitalone1

Then what are we to do? Sometimes if feel that I am wasting time querying and then not being coded. I have only been doing this 5 mths and I am already feeling discouraged and most of all, frustrated.

dvitalone1

My coding supervisor told me "how would you like it if a coder told you that you were doing something wrong related to nursing since you have been a nurse for 20yrs! Put yourself in their shoes" How do we make to coders understand we are here to help them not point out their errors.

cbarnes

I wish I had a good answer for you. All I can say is be persistent, be accurate, be patient and be ethical in your approach. Use all your resources available to make your case and constantly reeducate yourself.

I try not to "fight" w/ the coders. We bring alot of charts to task force for discussion. Our coders work from home so that is a communication hurdle. Often we only see them once a month. Interestingly enough, when we're all together sometimes another coder will explain her rationale for using a dx that the coding supervisor is antsy about and that smooths the way.

We have made our leaders aware of the supervisors attitude and there have been some behind-the-scenes discussions.

We constantly self-audit. Right now, we are collecting data on charts we think the lower DRG might be picked even when 2 conditions are both equally txed and responsible for admission.

Our jobs are important but I tell myself that @ the end of the day " @ least no one died on my watch." Enjoy your successes and contemplate your defeats. Another day will always bring new things.

hollyf1

Below is your reference for reporting additional diagnoses: if the diagnosis "emaciation" has one of the criteria below, then it should be coded.


Section III. Reporting Additional Diagnoses; p93-94
ICD-9-CM Official Guidelines for Coding and Reporting (effective 10/1/10)

General Rules for Other (Additional) Diagnoses
For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:

clinical evaluation; or

therapeutic treatment; or

diagnostic procedures; or

extended length of hospital stay; or

increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), p31038-40.



Holly Flynn, RN CCRN
Medical Quality Improvement Consultant
University of Washington Medical Center
Seattle, Washington

david.smith

I'm sorry to see all the talk of the animosity and struggle between the CDI staff and the coding staff. I guess I am lucky here since CDI is within the HIM Dept and I come from a HIM background.
I think the major issue here is one of those cases where the clinical diagnostic term does not equate to the ICD-9 code. Much like the whole issue surrounding Kwashiorkor (which has been somewhat resolved through Coding Clinic), the clinical statement of severe protein malnutrition led the coder to Kwashiorkor which was not a correct diagnosis to report 99.9% of the time and is now an easy RAC target. It seems that the fact that "emaciation" takes the coder to nutritional marasmus is causing a similar problem. If you look at the coding tree logic, the devil is in the details. The term emaciation will lead you directly to Marasmus, however if you start with malnutrition you will most likely be led to a severe protein-calorie malnutrition (262) which "seems" much more accurate in description. The only way I could get to marasmus following the malnutrition logic is to choose severe and then unspecified/other (if you were to choose protein-calorie you get 262!).
I think the key in getting agreement across the board may rely on clearly establishing the TYPE of malnutrition in very specific terms. If the patient has nutritional marasmus, then get that documented. If it is severe protein-calorie(energy) malnutrition then that should be documented.

cbarnes

Hello All- Thanks for all the feedback on emaciation. Charlene

kmaritan

The definition by Jolene below is for 261. However, please see this Coding Clinic 4th quarter 1992:

Malnutrition Codes

Malnutrition is generally thought of as a problem associated with children. Increasingly, it is becoming a problem for the elderly of this country who are unable to properly care for themselves, and who do not have the resources to obtain daily care.

Category 262, Other severe protein-calorie malnutrition, and category 263, Other and unspecified protein-calorie malnutrition, contain inclusion statements that define malnutrition in terms of weight for age, which is a standard method for classifying childhood malnutrition.

Effective October 1, 1992, all the inclusion statements from the malnutrition codes have been deleted. With this change, it is hoped that coders will no longer feel restricted in the use of these codes and use these codes for all age groups, not just children, as the original inclusion statement implied.

In order to improve the reporting of malnutrition among the elderly, it is important for physicians to document the condition in the medical record and for coders to be aware of malnutrition as a potential diagnosis.

jolene.file

Thanks for sharing, Karen.