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Malnutrition Coding 101
Author(s) -
Giannopoulos Georgia A.,
Merriman Louise R.,
Rumsey Alissa,
Zwiebel Douglas S.
Publication year - 2013
Publication title -
nutrition in clinical practice
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.725
H-Index - 71
eISSN - 1941-2452
pISSN - 0884-5336
DOI - 10.1177/0884533613508788
Subject(s) - medicine , malnutrition , reimbursement , documentation , medical classification , coding (social sciences) , medical record , parenteral nutrition , protocol (science) , population , intensive care medicine , nursing , family medicine , pediatrics , medical emergency , health care , surgery , environmental health , alternative medicine , pathology , statistics , mathematics , computer science , economics , programming language , economic growth
Recent articles have addressed the characteristics associated with adult malnutrition as published by the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). This article describes a successful interdisciplinary program developed by the Department of Food and Nutrition at New York‐Presbyterian Hospital to maintain and monitor clinical documentation, ensure accurate International Classification of Diseases 9th Edition (ICD‐9) coding, and identify subsequent incremental revenue resulting from the early identification, documentation, and treatment of malnutrition in an adult inpatient population. The first step in the process requires registered dietitians to identify patients with malnutrition; then clear and specifically worded diagnostic statements that include the type and severity of malnutrition are documented in the medical record by the physician, nurse practitioner, or physician's assistant. This protocol allows the Heath Information Management/Coding department to accurately assign ICD‐9 codes associated with protein‐energy malnutrition. Once clinical coding is complete, a final diagnosis related group (DRG) is generated to ensure appropriate hospital reimbursement. Successful interdisciplinary programs such as this can drive optimal care and ensure appropriate reimbursement.