Automating Malnutrition Diagnoses from Dietary Notes

This week I’m continuing my focus on defining documentation, this time with a real-world example that many of you may have encountered.

As noted last week, many electronic medical records (EMRs) include content importing technology (CIT). A somewhat common practice that may be problematic is when a malnutrition diagnosis is imported into a provider note from a dietary note.

The term “provider,” according to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year (FY) 2025, “means physician or qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnoses (p.1).” There are situations when documentation by other clinicians may be used to support code assignment, but the “associated diagnosis must be documented by the patient’s provider (p. 16).”

Dietitians are specifically cited in this guideline, but in reference to obtaining a patient’s body mass index (BMI) when an associated diagnosis has been established by the patient’s provider. Although dieticians may be experts on identifying and treating malnutrition, coding guidelines do not endorse the use of their documentation to either establish the diagnosis of malnutrition or to capture the degree of malnutrition.

This specific topic was addressed within the American Hospital Association (AHA) Coding Clinic for ICD-10-CM (First Quarter 2020), in the form of a question on whether the final impression on the dietitian’s consultation of severe malnutrition can be used to specify the degree of malnutrition when malnutrition was already documented by a provider. The response was, “No, there are no guidelines permitting the use of a registered dietician’s documentation of the degree/severity of malnutrition for code assignment.

The degree/severity of malnutrition (i.e., moderate, mild, severe) is a part of the diagnosis of malnutrition, which can only be made by the provider (p. 4).” In other words, the dietitian’s findings cannot stand on their own. This is where CIT is a solution adopted by many healthcare organizations. The dietitian’s assessment and finding may be automatically pulled into the provider’s note, but should it be considered physician documentation? What if the provider imports the dietary findings into their note – does that make it acceptable to use as provider documentation? 

Here’s another question that was addressed within the same AHA Coding Clinic issue. Is it appropriate to assign a code for severe malnutrition if the provider reviews the information and signs off or attests to it? The response was that it is beyond the scope of the Editorial Board for Coding Clinic to address this type of documentation issue, but they added that hospitals may develop a facility-based policy to determine if this is allowed for coding purposes. Unfortunately, hospital policies are not binding with payors, unless addressed within contract language.

I think it may be helpful to consider the role of other providers in code assignment for the inpatient setting. Code assignment may be based on other physician documentation, as long as there is not conflicting information from the attending physician (Coding Clinic, First Quarter 2004). A dietitian is a licensed clinician, but they are not medical providers and are not allowed to establish diagnoses, per the Official Coding Guidelines.

The AHA Coding Handbook states, “Although the pathologist or radiologist provides a written interpretation of a tissue biopsy or an X-ray image, that is not equivalent to the attending physician’s medical diagnosis, which is based on the patient’s complete clinical picture.” This statement is supplemented by AHA Coding Clinic (Third Quarter 2016), which noted that “there is a difference in coding documented clinical diagnosis from the attending physician and unconfirmed findings . . . It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient. The plan of care is based on the attending physician’s evaluation, interpretation and collation of all the findings (i.e., pathology, radiology, and laboratory results) (p. 25).”

The dietician is not a consulting physician, and not a non-treating provider. Maybe the dietitian’s finding should be treated as an abnormal result that needs to be interpreted by the attending physician, in the context of the clinical picture?  Wouldn’t their documentation be similar to that of a non-treating radiologist? An expert providing an opinion that needs interpretation by the treating medical team? 

Unfortunately, this specific topic is not addressed by the Centers for Medicare & Medicaid Services (CMS), which has criteria governing attestations, but mainly focuses on signature requirements. The issue with pulling dietary notes into a medical note is not the provider’s signature, but determining if or when it can be considered a reportable diagnosis. The closest reference I could find is the documentation of medical students. CMS has noted that a teaching physician must personally perform (or re-perform) the physical exam and medical decision-making activities of the E&M service being billed but “may verify any student documentation, rather than re-documenting this work.” Since the diagnosis of severe malnutrition can impact payment, would this CMS guidance apply? Therefore, is importing the diagnosis of severe protein calorie malnutrition from a dietary note sufficient?

The CMS MLN Fact Sheet “Complying with Medical Record Documentation Requirements” states that for a claim to be valid, there must be sufficient documentation to justify the level of care billed. Therefore, countersigning the dietician’s note is likely better than just importing the diagnosis, to ensure that supportive documentation is easily accessible by auditors. Comprehensive Error Rate Testing (CERT) has specifically identified the documentation error of incomplete progress notes, which may apply to this situation.

Lastly, although I know the Uniform Hospital Discharge Data Set (UHDDS) criteria for reporting secondary diagnoses does not require treatment, I have always advised that there are some diagnoses for which the treatment will help clinically validate the diagnosis. Severe malnutrition is one such diagnosis. Examples of this perspective are included within the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit findings of severe malnutrition, where they cited examples of claims for which severe protein calorie malnutrition was billed, but the patient was only treated with a heart-healthy diet and oral protein supplement. Their rationale was that the diagnosis did not affect patient care.

In conclusion, dietary assessments are a great tool for clinical documentation integrity (CDI) and coding professionals, especially if there are automated processes that identify when malnutrition is not fully documented by a treating provider or a lack of clinical evidence. The CDI professional is more likely to consider the complete clinical picture to determine if the diagnosis is reportable and clinically validated. If the goal is to bypass the CDI workflow, a best practice would be for the provider to state that they have reviewed the dietary assessment with a requirement to enter their own diagnosis, rather than merely importing or confirming the dietitian’s diagnosis of severe protein calorie malnutrition.

Programming note: Listen live today on Talk Ten Tuesday 10 Eastern for the CDI report with Cheryl Ericson.