Malnutrition Severity

jillian.bisbe

We are finding ourselves in this situation a lot with Malnutrition.

Dietitian is consulted- writes a beautiful note with ASPEN criteria and notes patient is at risk for Severe Malnutrition (spells out each criteria with supporting documentation). Query is sent and attending physician 'A" answers "Moderate Malnutrition". Providers change and attending physician "B" changes documentation to severe malnutrition in daily progress notes. Sometimes the same note even says moderate malnutrition in one place and severe malnutrition in another.  

Do you code to the highest level of severity (if it is supported)? Or Do you query AGAIN for conflicting documentation? It feels like we cant win sometimes- even if its conflicting and we query sometimes it continues to conflict! 

bbogda@morrishospital.org

Very frustrating.  We would code to the highest severity if supported, unless contradicted on discharge summary.  If contradicted on discharge summary, we would contact provider who dictated report and clarify to see if (s)he was in agreement with the higher severity.

afrady@blr.com

This is a common problem.  Unfortunately, there may not be an easy solution.  One doctor’s severe is another doctor’s moderate.  Malnutrition is a highly subjective diagnosis.  Physicians often view acute weight loss as a result of an acute illness as integral to the disease process.  Changes in body habitus over time that are representative of the nutrition are not easily quantifiable and therefore difficult for physicians to measure and render an opinion upon given the short nature of an acute hospital admission.  Even the registered dietitian’s assessment must be based on an interview with the patient which can yield an unreliable history.  To be honest. many physicians feel that correcting the malnutrition simply means treating the underlying diseases which are contributing to the nutritional issues therefore not something that needs to be separately addressed.  Lastly you need to consider if the resource utilization on the part of the hospital was sufficient to merit the reporting of a major complicating comorbidity.  Anyone who knows me knows that I used to be very aggressive in pursuing malnutrition diagnoses.  Unfortunately, with the attention from the OIG and the inappropriate denials I am seeing from the OIG subcontract auditors I cannot in good conscience advise you to be super aggressive with this diagnosis.

bbogda@morrishospital.org

Jillian states: Dietitian is consulted- writes a beautiful note with ASPEN criteria and notes patient is at risk for Severe Malnutrition.  In this case the patient appears to qualify for severe malnutrition.  I would clarify with the doctor for severe malnutrition. I believe we must code for the appropriate diagnosis even if the payer denies it.  We should not be afraid to code what is correct for fear of denial.  It is their job/gaol to deny.  It is our job to correctly code the chart.  In this case it is the diagnosis on the discharge summary that holds the weight - if you are confident in the diagnosis, clarify and get it on the discharge summary.

afrady@blr.com

bbogda@morrishospital.org said:

- if you are confident in the diagnosis.

That is the key phrase.       The trigger for controversy (well, at least one of them), is not simply the existence of the disease, but was the treatment rendered sufficient for reporting.

I do not like it any more than you do (trust me), however I just report the news..I don't make it (Don't shoot the messenger).  

I joke that the auditing powers have apparently cured malnutrition (even though the NIH says it is impacting up to 30% or more of the elderly population) by simply creating metrics which are difficult to 'prove", and that I can't wait until they come up with something that makes it hard to "prove" one has died...as we might then be able to live forever.