Conflicting documentation

littlebit_62703@yahoo.com

I have a case where a provider states mild malnutrition and the dietician says severe malnutrition the attending physician said nothing on discharge summary. Are your facilities querying the attending for conflicting severity levels per coding guidelines or just coding mild ? Our CDIs refuse to query any thoughts? Thanks

cindys@hollandhospital.org

Query

Our query would give  the RD assessment of severe malnutrition and the 2/6 malnutrition criteria and treatment and asks if the provider agrees. 

vparent@emhs.org

I concur with quincy above, we would do the same.

evanspx@sutterhealth.org

littlebit_62703@yahoo.com said:

I have a case where a provider states mild malnutrition and the dietician says severe malnutrition the attending physician said nothing on discharge summary. Are your facilities querying the attending for conflicting severity levels per coding guidelines or just coding mild ? Our CDIs refuse to query any thoughts? Thanks

I would issue a query, and in the query, I would cite the MD's  evaluation of mild malnutrition and the RD Assessment of severe malnutrition.  I think this is important for context. 

I'd ensure there is clinical support for the severe malnutrition and the query would ask the MD to indicate the 'best' classification for the conflicting documentation.

Paul Evans, RHIA, CCDS

afloyd24

We have received denials for this type of conflicting documentation.  Query for sure.

lprescott1

Agree with the query and Paul states a very important piece to this decision- 
"I'd ensure there is clinical support for the severe malnutrition and the query would ask the MD to indicate the 'best' classification for the conflicting documentation."  meaning if there is no support for the severe i would likely not ask the attending and stay with the "mild".

littlebit_62703@yahoo.com

Thank you all for your input. So this would be conflicting documentation because of the degrees correct? My coworkers and the CDS believe this is not conflicting documentation since we cannot code from the RD and that the attending MD does not have to agree with the RD diagnosis. To me this is still conflicting because of there are different degrees of malnutrition documented no matter how you look at the case. Aren't we supposed to have complete and accurate documentation? I am also being told that the DS overrides everything so no need for a query when the degrees are different in the record to just go by what is on the DS. I cannot perform clinical validation because I am not qualified to do so but I think someone needs to so this is coded accurately and maybe even talk to the RD to see what criteria are they using if not Aspen? any thought would be appreciated. Thanks

evanspx@sutterhealth.org

Complicated scenario that can't be fully discussed via this forum. My concern is that often an MD will use to a great extent the evaluations made by the RD when malnutrition is in the mix.   In my view, one issue is  that the subject-matter expert , (RD) evaluation is so very different from the charting by the MD - this would cause me to seek clarification.  (See ACDIS White Paper for Validation Tips and Background).  

 I view this in the same way as when I see an RN state the patient has a Stage 3 decubitus, and the MD states the patient has a Stage 2.  The evaluations need to be consistent, particularly for topics such as malnutrition, sepsis, pressure ulcers, encephalopathy, etc.  that we know are being scrutinized by 3rd parties.   Another example would be charting of coma  by one clinician, and yet the RN describes a patient awake, alert, conversant and lucid.  The elements of the record need to be consistent.

 In regards to the DS - yes, it is considered the Gold Standard for coding purposes, but if the DS documents a condition that may not be supported, clarification is in order

Paul