Q&A: Recommendations not being fulfilled

Q: If the medical record includes documentation of the dietitian recommending the administration of Glucerna, Ensure, etc., can we capture that? Even if the recommendation was never ordered or given? Or does it have to be an actual treatment that was both ordered and done?

A: Dietitians may make recommendations to providers as any consulting clinician can. However, if the provider does not adopt the recommendations and order what is being suggested by the dietitian, then no treatment was actually provided.

Let’s look at the following example. The dietitian diagnoses the patient as having severe protein calorie malnutrition and recommends nutritional supplements. The provider, who is legally accountable for establishing a patient’s diagnosis, does not adopt the recommendations and continues the patient on a regular diet. In this scenario, the treating physician is not supporting the diagnosis of the patient having severe protein calorie malnutrition. If the CDI professional brought that forward and the coder coded it, it would, in fact, likely generate a denial.

A diagnosis of severe protein calorie malnutrition requires more than just a regular diet as treatment. A diagnosis may meet the Uniform Hospital Discharge Data Set (UHDDS) definition of a reportable diagnosis related to assessment or evaluation, but if no treatment was performed for the condition, there is nothing justifiably being billed. If the patient was discharged on a regular diet, it simply does not support that the patient has severe calorie malnutrition, and a clinical validation query may need to be sent to clarify the scenario.

For those unfamiliar with UHDDS, it defines secondary diagnoses as “conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.” 

The UHDDS also gives us criteria to be met that is outlined in the FY 2021 ICD-10-CM Official Guidelines for Coding and Reporting, Section III, General Rules for Other (additional) Diagnoses.  The guidelines state that “for reporting purposes, the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring.”

Let’s look at sepsis as another example. The diagnosis of sepsis is documented and the patient is on broad spectrum intravenous (IV) antibiotics, however the IV antibiotics are de-escalated on day two. The question then becomes, would a serious systemic infection that is traveling to every organ in the body require more than two days of IV antibiotics to eradicate it? The answer is yes, it would. So, the next question to ask is what are they treating? Are they de-escalating antibiotics altogether? Because if so, that would indicate that there is no infection being treated so sepsis becomes very vulnerable as a coded diagnosis, because without a localized infection, there is no systemic infection. Sepsis may very well meet the definition of the UHDDS definition, but if it’s not being treated in a manner that is commonplace for a true septic scenario, then the diagnosis becomes vulnerable and is subject to denial as the treatment is not supporting the sepsis sequela.

There are varying degrees of both scenarios and they will vary from patient to patient. I think the important thing to takeaway for your CDI practice is to interrogate the record and ask yourself, “does the treatment match the diagnosis in severity?” If the answer is no, then you should consider if a clinical validation query is needed.

Meeting the UHDDS definition of a principle or secondary diagnosis is only the first step in the CDI review process. We need the true clinical picture being painted in the documentation, which involves treatment provided for the severity of the condition.

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