Malnutrition is an audit target of the HHS Office of Inspector General, Medicare administrative contractors and private payers.[1] Here are documentation tips from Deloitte Advisory. Contact Leslie Slater, a specialist leader at Deloitte Advisory in New York City, at leslater@deloitte.com.
Common Nutrition Documentation Concerns
Documentation questions often arise over criteria and to whom the documentation is attributable
| Question/Comment | Reply |
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Nutrition – “I do not feel comfortable documenting a diagnosis.” On occasion a nutritionist or dietician has voiced concern over being penalized for making a nutrition diagnosis, as they are not physicians. | It is perfectly acceptable for a nutritionist to document that a patient meets criteria for, or is at risk for, a certain degree or type of malnutrition. |
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Providers – “I do not know the criteria.” Many providers do not know ASPEN or GLIM criteria, and some are still using older criteria of albumin and prealbumin levels. Providers have also expressed frustration about the length of some clinical documentation integrity (CDI) queries that contain all malnutrition criteria. | Diagnoses can only be coded from documentation by a treating provider (PA, NP, physician, etc.) The treating provider is the one legally responsible for documentation in the record. Clinical indicators from the dietary note may be used by CDI or Coding to create a provider query; however, the provider is responsible for establishing or declining a diagnosis. |
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Providers – “I can tell just by looking at a patient whether they are malnourished.” Some providers will base a diagnosis on patient appearance or older criteria such as albumin and prealbumin. |
If a dietary note is well written and contains information that malnutrition criteria is met, the CDI specialist can use this information in a query to the provider for nutrition documentation clarification. Providers are free to document a condition using different criteria; however, this may lead to a CDI clarification query for conflicting documentation. The provider can choose to agree or disagree. |
