Monday, April 23, 2018

Tip: Using ED Documentation That’s Absent from the Discharge Summary

by Laurie L. Prescott, RN, MSN, CCDS,CDIP, CRC

Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the discharge summary contains all diagnoses treated during the stay, coders can report diagnoses written anywhere within the record, including the ED record. Think of that patient who has an extended stay—conditions that were reported and documented within the first 24 hours that then resolve early may not be included in the discharge summary. That doesn’t mean they shouldn’t be reported.

That said there are a few things to consider.

The principal diagnosis must be documented by the attending provider and we teach that it must also be included in the discharge summary. It’s hard to defend the choice of principal diagnosis if was not included in the discharge summary.

Documentation by the ED physician can be reported, as long as it does not contradict the attending provider’s documentation. Conflicting documentation should always be clarified with a query.

A query should be placed if the ED physician states a significant diagnosis and it’s never mentioned in the record again. Query with the relevant clinical indicators to support this diagnosis and ask the attending if he or she agrees with the ED provider. Technically, we don’t have to do this, but if the diagnosis is one that will significantly affect the final coding, it should be followed through by the attending. Conversely, if the ED provider mentions a secondary diagnosis that is not as significant—perhaps a chronic condition or a diagnosis that provides less impact—and I see evaluation/treatment/monitoring provided, I would not necessarily query the attending for confirmation.

I suggest that each organization works together to decide when to report a diagnosis that isn’t mentioned in the discharge summary, or when a diagnosis can be reported based on the ED provider’s documentation. Openly discuss the guidelines related to reporting of diagnoses and work with your coders to define consistent organizational practices.

Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at  For information regarding CDI Boot Camps, visit

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission.

Monday, April 16, 2018

Diagnosing and Documenting Malnutrition

by Nadia Pshonyak, RD, LD and Ashley Cheryholmes, RD, LD

It is estimated that malnutrition is prevalent in more than 50% of hospitalized patients and is associated with higher healthcare costs, length of stay, and increased morbidity and mortality. Until recently, no universal definition of malnutrition was available, resulting in inconsistencies in diagnosing malnutrition. In order to standardize diagnosis and documentation of malnutrition, The Academy of Nutrition and Dietetics (Academy) and the American Society of Enteral and Parenteral Nutrition (ASPEN) developed a consensus statement in 2012 that identified adult malnutrition as “an acute, subacute, or chronic state of nutrition, in which a combination of varying degrees of overnutrition and undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.”

ASPEN/Academy criteria utilize an etiology based approach to diagnose malnutrition which incorporates the role of the inflammatory response on malnutrition.  Inflammation is defined as an increased concentration of inflammatory mediators.  The inflammatory response can be acute or chronic. The presence of inflammation can increases the risk for or worsen the severity of malnutrition. In acute illness or injury there is decreased response to nutrition interventions and potentially increased mortality. Therefore, early nutrition interventions play a big role in improving patient outcomes.

After determining the etiology of malnutrition, 6 standardized diagnostic characteristics are used to identify the severity of malnutrition. These include: insufficient energy intake, unintentional weight loss, loss of body fat, loss of muscle mass, fluid accumulation, and diminished functional capacity. To diagnose malnutrition, two or more of these characteristics must be present.  Malnutrition is then identified as moderate, or severe.

The process of diagnosing malnutrition starts with identification of a patient at nutritional risk using a standardized screening tool.  Examples of common screening tools being used today include: Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), and The Nutrition Risk in Critically ill (NUTRIC). It is recommended that the malnutrition screening tool be appropriate for the patient population being served. Screening is required by The Joint Commission to identify patients at nutrition risk and should be completed by a trained clinician within 24 hours of admission to the hospital.  Patients identified at risk are then referred to the dietitian for assessment.
Once the RD receives a referral for an at risk patient, a full nutrition assessment is completed. The RD will review the patient’s anthropometrics, intake, weight history, medical history, labs, medications, diet orders and conduct a nutrition focused physical examination. After the RD has fully assessed the patient, a nutrition diagnosis can be made. 

Once the dietitian has determined the etiology and degree of malnutrition and has documented it in the medical record, a Licensed Independent Practitioner (LIP) should be notified to document malnutrition in their note. If the RD has provided written documentation about malnutrition, but provider has not added it also as a medical diagnosis, then the billing specialist may query the provider/LIP to obtain agreement with the dietitian’s documentation. Billing specialist may also follow up with the dietitian for documentation clarification. Providers must always include an intervention for each diagnosis. For malnutrition, the plan can simply be to consult the dietitian, refer to the dietitian note, or provide supplements and/or nutrition support.

Identifying and documenting malnutrition in hospitalized patients is important to improve patient outcomes, reduce length of stay, healthcare costs, and the risk for morbidity and mortality. Each hospital should put forth their own policies and procedures for identifying and documenting malnutrition based on evidence based guidelines as determined by their multidisciplinary team. Overall, establishing the presence and degree of malnutrition should be a collaborative process.


Nadia Pshonyak is a Registered Dietitian and has been working with the Cleveland Clinic Healthy System for over six years. She got her B.S. in Nutrition and Dietetics from the University of Akron in 2011. Nadia is a member of the Malnutrition Committee and is actively involved in a malnutrition initiative to educate dietitians and other healthcare professionals about diagnostic criteria for malnutrition.

Ashley Cherryholmes has been a Registered Dietitian for 5 years. She graduated from The University of Akron in 2013 with a B.S in Nutrition and Dietetics. She has been with Cleveland Clinic Healthy Systems for over 4 years.

Tuesday, April 10, 2018

2018 AHIMA Advocacy Summit – Part 2

by Peggy Kilty, MA, RHIA

While the cherry trees have yet to find their foliage on these brisk spring mornings in Washington, DC, the AHIMA membership was in full bloom for the 2018 AHIMA Advocacy Summit. This annual event unites health information professionals from across the nation to support the HIM vocation and to promote our professional interests with policymakers. This year’s summit provided participants with the power of a communal voice and a platform for patient advocacy. There was an emphasis on the relevance of relationships within our HIM community and with leadership at all levels of government. The summit confirmed the importance of collaboration not only with our HIM colleagues, but also with the many agencies working to improve the policy and delivery of healthcare in these United States.

Proudly representing OHIMA with Lauree Handlon, I flew into DC the day before the March 19-20 summit to take in the geographic and political landscape. My metro ride from the airport to the stop near our hotel established that is a city that embraces public policy as much as it embraces public transportation; I looked forward to embracing both on this journey to serve the HIM profession and the OHIMA membership. 

Day 1 Preparation: Inspiring Leadership, Influencing Change 
This was my first opportunity to participate in an AHIMA event at the national level. It was exciting and empowering to be in the presence of so many passionate and influential HIM professionals!  The Summit brought together leadership from fellow CSAs, our AHIMA Board of Directors and the fine folks from AHIMA Federal Relations (Pamela Lane, MS, RHIA, CPHIMS and Lauren Riplinger, JD). At the helm, our new CEO, Dr. Wylecia Wiggs Harris (or as she stated, just “Wylecia”), welcomed us to the event in the same way we welcomed her to our organization and profession—with enthusiasm, admiration and appreciation.

After Pam Lane, Vice President of Policy and Government Relations for AHIMA, enhanced our understanding of advocacy and how to influence change with state and federal lawmakers, we were introduced to AHIMA Foundation Communication’s Specialist, Mary Taylor-Blasi who gave us an update on the progress of the AHIMA Foundation’s Apprenticeship Program. As an emerging HIM educator, this topic was of great interest to me; HIM students are constantly crossing that bridge to become HIM professionals and need mentoring to make the journey. The apprenticeship program is an excellent support structure for that bridge! The program is a result of a five-year grant funded by the US Department of Labor. Some of the grant deliverables include:
  • 1000 Registered Apprentices (As of 3/16/18 there are 125 registered apprentices)
  • 200 Registered Employers (As of 3/16/15 there are 36 registered employers)

Several apprenticeship roles have been developed for this program and include:
     •  Hospital Coder/Professional Coder
     •  Medical Coder/Biller
     •  Professional Fee Coder
     •  Clinical Documentation Improvement Specialist
     •  Data Analyst

This apprenticeship program is an exciting, educational opportunity for HIM students seeking a professional pathway and is mutually beneficial to employers filling their HIM employment gaps. For more information on this program, contact the AHIMA Foundation at

As Lauree mentioned in her Part 1 blog post, we listened to speakers from the HHS OCR, ONC, and CMS. Genevieve Morris, MA, who serves as the Principle Deputy National Coordinator of the ONC, spoke to us about the ONC’s goal of improving interoperability through the Trusted Exchange Framework and Common Agreement (TEFCA). The goal of TEFCA is interoperability of electronic health information for all for as required by the 21st Century Cures Act legislation. The Draft Trusted Exchange Framework was released this past January. It consists of Part A—Princples for Trusted Exchange and Part B—Minimum Required Terms and Conditions for Trusted Exchange:



The overarching goals of the Draft Trusted Exchange Framework are five-fold:
    1.  Build on and extend existing work done by industry
    2.  Provide a single “on-ramp” to interoperability for all
    3.  Be scalable to support the entire nation
    4.  Build a competitive market allowing all to compete on data services
    5.  Achieve long-term sustainability

The final version of TEFCA is due for publication in the Federal Registrar later this year.

Day one preparation continued with a review of our legislative branch of government. It was reminiscent of a civics course—but with a twist that I’ll call “All the Things your Civics Teacher Didn’t Tell You About Congress”. Lauren Riplinger, AHIMA’s Senior Director of Federal Relations, has served in several congressional office roles—including Chief of Staff—which allowed her to provide us with an insider’s view of the inner workings of Capitol Hill. With a clear understanding of AHIMA’s two “asks” to Congress, we were well prepared for our legislative visits scheduled for the next day.

My thoughts at the end of day one: AHIMA and its membership have strength in leadership at their core. Together, we have a powerful voice. Through our advocacy efforts, we are earning a high professional and public profile on the Hill and in our home states. We have collectively raised attention and awareness around the issues that impact our ability to serve HIM in a professional capacity. We can influence and advise makers of public policy that impact the HIM profession. But it is only when we, in the words of Wylecia, “Show up and show out” can we do those things and make a difference. 

In this photo: AHIMA 2018 Advocacy Summit participants showing up and showing out

About the Author

Peggy Kilty began her new position as Clinical Instructor, Health Information Management & Systems Division at the Ohio State University’s School of Health & Rehabilitation Sciences in April of 2018. Her interests include clinical education, classification systems and student professional development. Prior to this, she worked as an adjunct instructor with Columbus State Community College’s Health Information Management & Technology Program where she taught Medical Coding and Reimbursement courses. She was previously employed by OhioHealth as an Inpatient Medical Coder. Before her career in HIM, Peggy was an instructor of undergraduate Spanish language classes at The Ohio State University. She has served nearly ten years as a Spanish language medical interpreter for various Columbus area community outreach health clinics.

Ms. Kilty recently completed post-baccalaureate studies in HIMS and earned her RHIA certification in December of 2018. She received an Associate of Applied Sciences in HIMT from Columbus State Community College and earned her RHIT certification in 2015. She received her Master of Arts degree in Latin American Literatures and Cultures in 2002 and her Bachelor of Arts degree in International Studies/Spanish in 1999, both from The Ohio State University. 

An active member and volunteer with the OHIMA Board of Director’s since 2014, Peggy looks forward to continuing her service to the OHIMA membership through advocacy for the profession.

Tuesday, April 3, 2018

Epistaxis Control

In the kNOW” this month tackles the topic of controlling epistaxis.  There are a variety of reasons that a patient will present with a bloody nose and several methods can be used by physicians to stop the bleeding.  Let’s take a look.

A 4 yr. old patient comes to the ER with a small, bleeding laceration on the right external nares after trying to shove a small toy up his nose.  The physician must use a suture to stop the bleeding.  ICD-10-PCS code assignment would center around the root operation of Control.  Remember, the definition of Control is stopping or attempting to stop postoperative or other acute bleeding.  So Control fits this scenario, and the code would be 0W3Q7ZZ for control of bleeding from respiratory tract via a natural or artificial opening as presented in the 4th Qtr. 2017 Coding Clinic.  This supplants information provided in the 4th Qtr. 2014 Coding Clinic when the root operation was determined to be Repair, which was prior to the definition change of Control.  If we want to assign a CPT code instead, it would be 30901, control nasal hemorrhage, anterior, simple. 

In a different circumstance, an 84 yr. old patient presents with epistaxis due to hypertension.  The bleeding is unrelenting from the anterior of the nose, and the physician decides to use a nasal tampon to control it.  While this is still a method of control, in ICD-10-PCS we have a guideline (B3.7) that tells us that when a more definitive root operation is available to specify the method of control, then we should use it.  In this scenario, Packing is the appropriate root operation as indicated in the 4th Qtr. 2017 Coding Clinic.  ICD-10-PCS code 2Y41X52 is the code we should apply.  Again, the CPT code assignment would be 30901 for the simple control of the anterior nasal hemorrhage.  If the packing was extensive, the CPT code would change to 30903.

As we can see, the key to the procedure code assignment in ICD-10-PCS is the root operation performed.  Understanding the root operation definitions will help us make the correct code choice.  In CPT, knowing the area of the epistaxis (anterior, posterior) and the extensiveness of the treatment will guide us to the appropriate code.

Now you are in the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.