1. Sample Physician Documentation Recommendations
Sample Physician Presentation
Sample Physician Documentation Recommendations
The patient presents with multiple risk factors for malnutrition such as significant recent weight loss, malignancy, chemotherapy and radiation and need for J tube feedings. An additional diagnosis of malnutrition (or weight related diagnosis) should be considered. The diagnosis of malnutrition requires the additional specificity of type and severity to accurately reflect severity of illiness (SOI)/(risk of mortality) ROM. Mild and moderate calorie (protein calorie) malnutrition are co-morbid conditions (CC). Severe protein calorie malnutrition is a major co-morbid condition (MCC). The secondary diagnosis of specified malnutrition can impact DRG assignment.
Observed
Potential
Principle Dx
Malignant Neoplasm of Esophagus (150.9)
Malignant Neoplasm of Esophagus (150.9)
Secondary DX
Severe Protein Calorie Malnutrition (262)
Principle Procedure
Total Gastrectomy (43.99)
MS-DRG
328 – Stomach Esophageal & Duodenal Proc W/O Cc/Mcc
Stomach Esophageal & Duodenal Proc W/ Mcc
Relative Weight
1.4765
5.6013
GMLOS
2.6
11.6
SOI/ROM
SOI: 2 (Moderate), ROM: 1 (Minor)
SOI: 3 (Major), ROM: 2 (Moderate)
Source: The Advisory Board. Used with permission.
The Advisory Board recommends providing physicians with one-on-one training that shows how specificity in documentation can impact the severity of illness. Here is a sample for malignant neoplasm of the esophagus.