CCDS Malnutrition Diagnosis and Documentation 5

Question 1

A CDS reviewing a chart notes the physician documents 'failure to thrive' in a geriatric patient with significant weight loss and muscle wasting. What is the best CDS action?

Accepted Answer

Query the physician to clarify whether malnutrition should be documented as an additional or principal diagnosis

Answer

Failure to thrive (R62.7) is a symptom code and does not equate to a malnutrition diagnosis; the CDS should query to determine whether a specific malnutrition code is appropriate.

Question 2

Which clinical scenario most accurately represents kwashiorkor-type malnutrition (ICD-10-CM E40)?

Accepted Answer

Severe protein deficiency with edema and relatively preserved body weight

Answer

Kwashiorkor (E40) is characterized by severe protein deficiency with edema (protein-losing state), distinguishing it from marasmus which involves caloric wasting without edema.

Question 3

When malnutrition is the principal reason for inpatient admission, what is the impact on MS-DRG assignment?

Accepted Answer

Malnutrition as principal diagnosis with severe severity increases the base DRG weight substantially

Answer

Severe malnutrition as a principal or CC/MCC diagnosis can shift a case to a higher-weighted DRG, directly affecting reimbursement.

Question 4

A physician documents 'nutritional deficiency' without specifying type or severity. The CDS should:

Accepted Answer

Query the physician for specificity regarding type and severity of the nutritional deficiency

Answer

Vague documentation like 'nutritional deficiency' lacks coding specificity; a query is required to capture the exact type and severity for accurate ICD-10-CM code assignment.

Question 5

Which statement correctly describes how malnutrition interacts with the Patient Safety Indicator (PSI) and Hospital-Acquired Condition (HAC) programs?

Accepted Answer

Present-on-admission (POA) status for malnutrition must be accurately documented to avoid HAC penalties if a complication arises during the stay

Answer

Accurate POA assignment for malnutrition is critical; if malnutrition is POA and a related complication occurs, the HAC penalty may not apply, protecting reimbursement.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Malnutrition Diagnosis and Documentation 5