Query Yes/No for Malnutrition
The information in this query is fictitious. I need your thoughts on if this type of query would be seen as non-compliant. I have been informed by one of coders that this is non-compliant because we are asking a provider to agree or disagree with a Nutritional Diagnosis. I disagree. Your thoughts please??
Dr. Smith,
Please review the following and provide your response in the progress notes.
Clinical Indicators
85-year-old female admitted for frequent falls, AKI, and cystitis
ED note indicates patient has been “eating less than 300 calories a day due to decreased appetite”
4/2 Nutritional consult note indicates, "25% weight loss in the last 6 months...has been eating 1 meal per day...15% weight loss in the past 3 months...has not ate in more than 2 days prior to arrival...edema noted"
Nutrition dx: “Severe Protein Calorie Malnutrition r/t achalasia, failure to thrive in adult AEB 15% wt loss in 3 months and less than 50% of estimated energy requirements for more than 5 days."
Treated with ensure with all meals, snacks between meals, and calorie count.
Do you agree with the dietician's nutritional diagnosis of Severe Protein Calorie Malnutrition?
- Yes
- No
- Other (please specify):___________________
- Unable to determine
Comments
I would not use Yes/No format in this situation.
Rationale: The RD is not authorized to independently establish a diagnosis for reporting purposes.
I would definitely submit a query, but I would not use the Yes/No Query format.
I use the Y/N format to ask an Attending to comment on or endorse some aspect of documentation of some condition that my be noted by an MD, NP, PA, or CRNA, but not an RD. Others may disagree?
Paul Evans, RHIA, CCDS
What if this was a multiple choice query? Same verbiage on top but then the choices of severe malnutrition?
IMO, there are definitely strategies we can use to ensure the nutritional status is reported, and a compliant query with valid and compliant multiple-choices as supported for each unique patient is the preferred strategy