CAPTURING BMI

dvitalone1

At our facility, we have a dietary coding clarification form. Dietary assesses all patients and documents on their assessment form. If pt has any form of malnurtion, obesity or morbid obesity Dietary documents this along with BMI in their record and on the dietary coding clarification form which the physician signature is required. My question is if dietary documents malnutrtion (any degree) and physician signs the form but it is never documented anywhere else in the record by physician, would it be appropriate to code the malnutrition & BMI from this form.

david.smith

The short answer would be yes, assuming your queries are part of the permanent record. However, I am somewhat uncomfortable with only having the documentation appearing once in the record and only on a query/clarification form especially when it comes to something that is usually POA and long-term problem. I have heard stories of auditors rejecting documentation that appears only on query forms, but I haven't experienced that personally.
One question on the process at your hospital, the dieticians are documenting the conditions on their assessment and then you are putting a dietary clarification on the record, correct? I wonder if you could streamline the process and just get the attending to co-sign the dietary assessment??

dvitalone1

Thanks for your response. We developed this form with collaboration of dietary and the coding supervisor. The reason we developed the coding clarification because there was no room for signature on the dietary assessment form. Instead of having the physician sign every dietary assessment we formed the clarification. When dietary identifies at pt, dietary places the coding summary on the chart with the information written in such as bmi, type of malnutrition, plan of care.

dbutler

I do have one concern -- how do you demonstrate that this meets the requirements of a reportable diagnosis? ie, that there were treatment, monitoring, additional resources, etc.? If you can not demonstrate that, then the diagnosis should not be captured. Doesn't need to be complex, but there does need to be something.

There are occasional cases where it is very difficult to support the follow through of the documented diagnosis, thus leaving the diagnosis open to challenge by RAC et.al.

Don

dvitalone1

I forgot to mention that the plan of care for the patient is written by dietary on the clarification form and in their assessment so when to MD signs the form they are also agreeing with the treatment plan