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Ask the Expert

This month’s selection:
Does the physician have to document the severity of malnutrition, or can we take the documentation from the registered dietitian’s notes?

Donna Ludwig, CCS

I can find no Coding Clinic or Faye Brown or Official Coding Guideline that permits coders to use nurse or dietitian documentation to support the severity designation for a physician diagnosis of malnutrition.
Additional information that may explain why it is tempting to do so includes the following:
Dietitians, nutritionists, and nurses can provide the information to code body mass index (BMI) per Faye Brown Coding Handbook 2009, chapter 11 under the heading for “Codes for Nutritional Disorders.” (The origin is the fourth quarter 2005 Coding Clinic, pages 96-98.)
However, this section also states that “this is an exception to the guideline that requires that code assignment be based on the documentation by the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.” Generally, this will also include physician assistants, nurse practitioners, and certified nurse-midwives working with the scope of their licenses. For example, a certified nurse-midwife would not be legally accountable for establishing a diagnosis of congestive heart failure in an elderly patient but would be able to establish the diagnosis of preeclampsia in a pregnant patient.
However, nurses, dietitians, and nutritionists are not authoritative in diagnosis; they treat what the medical practitioner has diagnosed.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for 20 years.