Q&A: Coding diabetes and malnutrition in pediatric patients
Q: I work at a pediatric hospital and am wondering if a newly diagnosed diabetic patient should also have malnutrition coded separately. While the dietician sees these patients routinely, the head of endocrinology explained she hasn’t been documenting the level of malnutrition because it’s temporary and due to the illness with the treatment being the initiation of insulin therapy. What are your thoughts?
A: I believe we may be mixing criteria here. The situation with acute hyperglycemia and hyporinsulinemia does not correlate well with any reporting definitions of malnutrition. As you may know, long term untreated hyporinsulinemia can lead to a lack of appetite and weight loss. That presentation alone, however, cannot be necessarily described as malnutrition. Malnutrition must be based on a facility defined, evidenced-based criteria made via an assessment by a treating provider.
Malnutrition in children is based on their failure to meet developmental milestones and deviations related to their z-score and the pediatric body mass index (BMI) scale. The American Society for Parenteral and Enteral Nutrition (ASPEN) criteria includes specific malnutrition definitions for children which looks at a broader data set (such as intake and strength, etc.) as well. If these findings are present and there is evidence in the record that it is clinically significant, then I would move forward with a clarification so that it can be properly coded.
Generally, I recommend an even more comprehensive CDI review which takes into account the disease states, psychosocial, economic, and cultural risk factors, as well as the general metabolic assessment of the child (several relevant areas which are not assessed by the dietician and are not presently part of ASPEN, etc.).
It is noteworthy that despite industry leaders’ opinions on the matter, recent audit activity has heavily scrutinized this diagnosis in adults not based on clinical evidence but based on a rather strict and dogmatic interpretation of a severely diminished patient presentation, and one which requires a great deal of hospital resources in the treatment. This will likely embolden both commercial auditors to follow suit with more aggressive audits and it could trickle down into the pediatric population, Medicaid, etc.
I generally do not encourage anyone to be overly conservative nor overly aggressive but rather to develop a policy which is likely to be defensible, based on sound clinical criteria, considers the reporting rules, and best identifies the clinical truth of the patient’s clinical situation.
Presently, however, we have no choice but to let our CDI specialists know that this diagnosis is being heavily (perhaps unfairly) targeted. Proceeding with caution could be the most prudent choice at the moment. I would move away from looking at this diagnosis as a quick pick up in diabetic children into a more holistic and complete standard which would need to be satisfied before reporting this diagnosis.
Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.