Q&A: Coding pediatric malnutrition

Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?

A: I think CDI has a huge opportunity. I found out about the huge opportunity that I had with my pediatric population when I started the pediatric and neonatal CDI program at my organization. I forged a relationship with our registered dietitian (RD) team. What can sometimes happen is that a CDI specialist might think, “I'm going to focus on the documentation aspect of this,” and miss that you're part of the care team as well. And sometimes in examining the documentation you find opportunities that you didn't necessarily realize that you had.

For example, a child is admitted on a Friday afternoon for failure to thrive (ICD-10-CM code R62.51). I look at the orders that have been placed, and I don't see an order for the RD. I can reach out to my dietitians and let them know, “A child was admitted on such and such a unit in such and such a room, and they were admitted with the diagnosis of failure to thrive. I don't see an order on the chart. This might be a child you want to swing by and see.” It will facilitate the process moving quicker. And once the dietician makes a plan, then everyone starts to execute the plan immediately. And so, you might see a shorter length of stay or just see things happening more quickly for the child. All of those are positives.

The documentation is also important. I don't want to downplay that. A lot of times the dietician will write very specific and very elaborate recommendations and that diagnosis of pediatric malnutrition and the severity of it doesn't get pulled over into the physician documentation, which is where it needs to be in order for that to be captured in our final coding. When that occurs, the RD note has so much information in order to formulate a query that it's usually adequate to help you to tell the story in the query. But sometimes within their recommendations, you can also pull other things from the chart. For example, if they've recommended daily weights, that might be something you want to include in the query just to bolster it. And then, of course, you want to note that within the RD note that they have diagnosed the child with severe protein calorie malnutrition (ICD-10-CM code E43), for example. And then you're going to put that in one of your choices and that becomes part of your legal medical record and part of their problem list.

So, those are the ways that CDI can really be involved in documentation.

Editor’s note: This Q&A was originally published in JustCoding. Amy Bush, BS, RN, MJ, CCDS, CCS, a CDI specialist III at Cooper University Health System in Camden, New Jersey, answered this question on The ACDIS Podcast.