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Specific, precise and clear documentation surrounding medical and surgical diagnoses and treatments are critical elements of all professional medical documentation, including protein-calorie malnutrition (PCM). To avoid improper payments for unnecessary diagnoses and treatments, the Center for Medicare and Medicaid Services (CMS) creates requirements for payers, infrastructures and audit systems to ensure that hospitals comply with federal regulations. Some commercial payers also model these requirements. CMS requires documented evidence that supports patients’ diagnoses, and that treatments are specifically described, connected to the diagnosis, and accurate.
Clarity and consistency are sometimes elusive in the auditing and coding industry in general, and more specifically for our purpose, regarding PCM. There is juxtaposition for clinicians because federal auditors are paid based upon successful payment denials rather than accuracy from a clinical viewpoint.
Unfortunately, there is no clear standard that hospitals or health professionals can use to ensure they comply with documentation standards for PCM and many other diagnoses. There is also no standard between auditors, so different auditors can accept or deny the same patient’s PCM diagnosis for different reasons. This paper discusses the process, history, sources of confusion and disconnections in medical documentation and coding, and provides suggestions for improving specificity and clarity in documentation of the diagnosis of PCM, with the intent to help reduce coding denials. There is no guarantee these suggestions will reduce denials; however, the more specific, clear and precise PCM is described by the dietitian, physician, and other healthcare professionals, the less risk there may be to the hospital.
CPE Level: 2
Learning Need Codes: 1070, 3005, 7170, 1140
Performance Indicators: 10.2.12, 3.1.6, 4.2.8
- The participant will be able to describe the medical coding process
- The participant will be able to clearly and specifically document the malnutrition diagnosis
- The participant will be able to implement actions to reduce the possibility of coding denials