Tip: Take advantage of nutrition month for your physician training

Documentation of both malnutrition and body mass index (BMI) affects MS-DRGs’ assignment as CCs or MCCs and can clarify the patient’s severity of illness as well as the complexity of care required to treat the patient, writes by Richard D. Pinson, MD, FACP, CCS principal of HCQ Consulting, in the October 2011 edition of the CDI Journal.

 

To qualify for code assignment, the BMI must be documented in the medical record by the physician, or by a clinician (e.g., a nutritionist or nurse). There must also be a clinical diagnosis or condition documented by the physician that corresponds to the abnormal BMI and thereby explains its significance, according to AHA Coding Clinic for ICD-9-CM, Second Quarter 2010, p. 15, and Fourth Quarter 2008, p. 191. A nutrition note may be the only place in the medical record where BMI is documented, and it may also provide clues to the underlying condition. Certainly, the presence of a nutrition note implies that an underlying condition is likely present, Pinson says.

 

At ARAMARK Healthcare’s Carondelet Health in Kansas City, MO, CDI professionals teamed up with dieticians to create a specific form regarding dietician’s nutritional findings for the physician to review and sign (read more about this partnership in the upcoming April edition of the CDI Journal).

 

Consider creating an educational poster of common nutrition-related query points and posting it in the physician lounge, or spearhead a documentation audit focused on malnutrition/obesity-related trouble spots during the remainder of March.

 

The following articles offer additional tips regarding documentation improvement opportunities associated with nutrition concerns: