Malnutrition severity

david.reecerndavid.reecern
in CDI Talk Archive
A discussion has come up recently at our facility regarding the severity of malnutrition and where that documentation can come from. Our coding department feels the severity can be taken from the RD notes since they are ordered to evaluate the patient by the attending MD. MDs are not importing the RD notes into their EMR progress notes or signing the RD assessment. I cannot find anything in the coding guidelines that supports this. Any thoughts from the group? Thanks

Comments

  • kerryseekircherkerryseekircher
    edited April 2016
    It would not be appropriate to pick up the severity of malnutrition from RD assessments. The physician must document both the diagnosis and the severity in order to be coded. The RD assessment can be useful when initiating a query as they often list clinical indicators, treatment options, and full nutrition plan, etc..The main point I would make to the coders is that the RD's are conducting an assessment, but the physician has to be the one to diagnose.
    Thanks,
    Kerry

    Kerry Seekircher, RN, BSN, CCDS, CDIP
    Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013




  • m.leblancm.leblanc
    edited April 2016
    I have always been taught that the diagnosis must be documented the provider.

    The CC that I am aware of states that the BMI is appropriate from RD or RN documentation but not the associated diagnosis which I would agree includes severity.

    Body mass index reporting clarification
    Coding Clinic, Second Quarter 2010 Page: 15 Effective with discharges: July 7, 2010

    Question:

    There has been some confusion as to whether nursing staff documentation is acceptable for assigning the body mass index (BMI). Since hospitals are allowed to code the BMI based on the dietitian’s documentation, it would seem reasonable to assign the BMI based on the nurse’s documentation as well. Can coders use nursing documentation to assign the BMI?

    Answer:

    Yes, the BMI may be assigned based on medical record documentation from clinicians, including nurses and dietitians who are not the patient’s provider. As stated in the Official Guidelines for Coding and Reporting, BMI code assignment may be based on medical record documentation from clinicians who are not the patient’s provider, since this information is typically documented by other clinicians involved in the care of the patient. Dietitians were only mentioned as an example of a clinician that might document BMI information.

    However, the associated diagnosis (such as overweight, obesity, or underweight) must be documented by the provider.

    Refer to the Official Guidelines for Coding and Reporting for additional discussion.

    Thanks,
    Mark

    MARK LEBLANC, RN, MBA, CCDS
    DIRECTOR CDI SERVICES

    952-353-3505
    m.leblanc@thewilshiregroup.net



  • angelisa.romanelloangelisa.romanello
    edited April 2016
    We query for malnutrition specificity if the physician documents: cachectic, cachexia, FTT, underweight and we have a RD BMI of less than 18 with an albumin of less than 2.8.
    Of course, if the physician documents malnutrition with no specificity, then we query for specificity based on that.

    We do not use a BMI taken from anyone other than the RD. However, we also pay close attention to the medical record as some people can live with a BMI of below 18 successfully and maintain a healthy lifestyle.

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