Q&A: Provider specification on malnutrition queries

Q: We’re having some trouble with malnutrition documentation. In many instances, the patient meets the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria and the provider agrees with the query, but then doesn’t expand on the diagnosis in their documentation. We’re then getting denials on the backend.

Do you have any advice on this situation? The dietician assessment is pulled into the progress note, but the provider is not specifically speaking to it. In these situations, the patient is being monitored and receiving supplements.

A: There are a few issues within this question. One is the use of the Aspen criteria by itself. The second issue comes when the only time the diagnosis is mentioned in the medical record is the query response,  because the provider did not add it to the progress notes. Both of these situations can lead to denials. 

Aspen is a great tool, but it will not likely be helpful by itself in times of an audit by the OIG, being that they have been focused on severe malnutrition. What I recommend is to also focus on the chronicity of the case so that the documentation is very clear about the chronic condition(s) that pave the way for malnutrition to exist, especially when it comes to severe malnutrition.

If you have the issue of providers not documenting the diagnosis in the record and you are receiving denials, that’s a physician education issue that needs escalation.  One thing that can help is if facilities take denials to the providers and have them assist with writing the appeals.  After all, it is their diagnosis being denied.

This issue is two-fold; it’s educating the providers to document their query answers in the progress notes (not just on the query form), and ensuring the chronic condition is well documented.  This will go a long way in denial prevention as long as the diagnosis is clinically supported. 

Lastly, the CDI specialists should look for contradictions in the record, such as statements of “well developed" or "well nourished.”  This is a huge issue derived from the usage of templates that is often overlooked.  I have found these statements in the physical exam portion of the emergency room notes and provider progress notes when I’ve audited cases in the past.  As long as we list these statements in a query when they conflict the nutritional status of the patient, we are clarifying the conflicting data and doing our due diligence to clarify the nutritional state of the patient.

It’s all about building that case with clinical indicators and showing the circumstances that are leading to the malnutrition, not just the indicators by themselves such as BMI or diet.

Editor’s note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist with HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.