By Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O
Thanks to the dietitian’s note, severe malnutrition was documented and reflected in the discharge summary. At first glance, it looked like it was buttoned up. The physician electronically signed it. The documentation is there. So why do we recommend a query?
Because sometimes, copy-paste isn’t documentation – it’s decoration.
In this edition of Query IQ, we’re tackling the question: Is it enough to carry a dietician’s note into the discharge summary to support coding for severe malnutrition? Spoiler: not usually.
The Case That Sparked the Question
During a recent DRG prebill review, we found a case where a dietician’s note diagnosing severe malnutrition (E43) was pulled directly into the discharge summary and electronically signed by the attending physician. Based on that, the diagnosis was coded.
From a distance, this might look like valid documentation. But when you zoom in, there’s no independent physician assessment, just a pasted note. There was no discussion of clinical significance, no mention of treatment or evaluation, and no confirmation that the provider reviewed or agreed with the dietician’s findings. While dietary consultation may be considered a form of evaluation, without specific documentation by the provider, many payors may argue dietary evaluation is routine in the hospital setting.
Think of It Like an Abnormal Finding
Let’s draw a parallel. When a patient undergoes a chest X-ray or CT on admission, the radiologist might report something abnormal – an infiltrate, for example. The provider often repeats that finding in their note:
“X-ray shows left lower lobe infiltrate and possible pneumonia.”
But per ICD-10-CM Official Guidelines Section III.B, that’s not enough. It states:
“Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. Suppose the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment. In that case, it is appropriate to ask the provider whether the abnormal finding should be added.”
In other words, it’s not reportable unless the provider comments on what the abnormality means – by diagnosing, treating, or ordering further evaluation. Just citing the test result isn’t enough.
The same concept applies to dietitian documentation, who isn’t even an independent licensed professional authorized to make reportable diagnoses.
Coding Clinic Contains a Similar Scenario
Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 4 touches on a similar issue: a dietician documents severe malnutrition, and the physician later electronically signs the note. The question was whether the provider’s e-signature alone makes it appropriate to assign the malnutrition code.
Coding Clinic declined to take a firm stance, stating that this falls under facility-level policy decisions. But here’s the reality: just because Coding Clinic defers to internal policy doesn’t mean it will hold up under payor review. In today’s environment, relying solely on an e-signature without clear physician attribution of clinical significance is a gamble that often results in denial.
A Better Approach to Querying
If your providers are electronically signing nutrition notes without incorporating the diagnosis of malnutrition into their own documentation, it’s worth stepping back to address the root cause. Consider a multi-pronged strategy:
- Educate physicians on the coding implications and denial risk when malnutrition isn’t directly acknowledged in their own words.
- Collaborate with physician leadership to develop a consistent, system-wide documentation standard for referencing dietician findings. The answer could be as simple as provider documentation “Agree with dietician assessment”.
- Query selectively, when the documentation leaves too much ambiguity — but don’t let queries become the default fix.
Sending the same query over and over isn’t a sustainable solution. Instead, use these moments to create clarity and consistency — not just for compliance, but for defensibility.
Final Takeaway
The physician’s signature doesn’t turn a dietitian’s note into a diagnosis.
Treat it like an abnormal test result requiring physician interpretation to be coded.
Empower physicians through education and collaboration to reinforce documentation accuracy and compliance.
Ready to strengthen your query practice?
Connect with Brundage Group for expert guidance on structuring compliant, clinically sound queries that protect revenue and reduce denials.
Ready to strengthen your query practice?
Connect with Brundage Group for expert guidance on structuring compliant, clinically sound queries that protect revenue and reduce denials.
