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Q:

Is the Registered Dietician’s documentation / finding of malnutrition enough to code malnutrition or is a diagnosis needed from the MD?

A:

The disease conditions in Section I require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. A Registered Dietician’s documentation would not meet this requirement.

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Blog by Kristen Walden, MSN, RN, RAC-CT, Clinical Consultant, Proactive Medical Review

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