Diagnosing and Documenting Malnutrition

By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor

Dieticians’ findings must find their way into the medical record to achieve proper care and coding.

Diagnosing malnutrition is not diving for dollars.

Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty healing from trauma or surgery, or recovery from acute or chronic illnesses. It leaves patients vulnerable to secondary conditions like vitamin deficiencies and skin wounds.

Have you ever heard of the term “prehabilitation?” The concept was developed to prepare patients for elective orthopedic surgeries by giving them strength training to prevent injuries. It is now being expanded to other surgeries, to include cardiopulmonary training and optimizing nutritional status. It is meant to give patients reserves to withstand physical challenges. Surgeons are recognizing that nutrition in particular matters.

Article originally published on December 12, 2017 by ICD10 Monitor.