Q&A: Insights regarding malnutrition diagnoses

Q: What are the key takeaways for diagnosing, documenting, and supporting malnutrition diagnoses (ICD-10-CM categories E40.- through E46.-)?

A: First, have a multidisciplinary approach in the sense that there should be a collaboration of various healthcare providers who will help address the complex and multifaceted nature of malnutrition. This approach is in place to ensure that the comprehensive care will target all aspects of the patient's condition while breaking silos between departments.

Using a uniform definition and criteria set for malnutrition diagnoses is equally important, because documentation and coding should be consistent across an organization. I’m not saying all providers have to document and assign diagnosis codes in the exact same way, but there should be some uniformity to it to avoid missing information. Not having the most appropriate information misrepresents the patient's clinical story or experience.

Remember that body mass index (BMI) can be recorded based on documentation from nurses, dietitians, or other clinicians, but a provider must document a diagnosis of malnutrition or obesity. The severity of malnutrition, whether it be moderate, mild, or severe, must also be documented by the patient's provider and cannot be coded based on documentation from a dietitian or other clinician.

The diagnosis of malnutrition cannot rely solely on the clinical indicators either. If clinical indicators suggest malnutrition, but it is not documented, the provider should be queried.

This is why it is necessary for CDI and coding professionals to be a part of documentation and query initiatives as well. I do believe, as an HIM professional, it is imperative that CDI specialists and coders collaborate because there is added value for using both clinical and coding knowledge. Partnering together in those capacities whenever possible is ideal.

Lastly, use the electronic health record (EHR) to communicate findings in a standardized way to providers. Anytime you allow the EHR to be the source of truth, you are covering all your bases by including clinical perspectives, revenue cycle perspectives, and regulatory and compliance perspectives.

Editor’s note: This question was answered by Cokethia Rachel, CPC, CCS, CPMA, SSBBP, owner of Coding Connection LLC and an HIM director based in Atlanta, and was originally published on JustCoding.