Q:
Can I code Malnutrition (Section I5600) on the MDS based on a dietary assessment that identifies the resident as at risk for malnutrition?
A:
No. Dietitian assessments alone do not provide sufficient documentation for coding of this item on the MDS.
All diagnoses coded in section I of the MDS must meet the RAI manual criteria for coding. Specifically, a physician (nurse practitioner, clinical nurse specialist, or physician assistant) documented diagnosis of malnutrition or risk for malnutrition in the last 60 days must be present in the record. The diagnosis should be clearly stated using specific terms, such as protein calorie malnutrition, severe malnutrition, and “at risk for malnutrition”. Vague terminology such as poor nutrition, at risk for weight loss or at risk for impaired nutrition should be avoided. Some facilities opt to have the physician sign the nutritional assessment completed by dietary to confirm their agreement with the nutritional risk assessment.
In addition, the diagnosis must be active during the 7-day MDS assessment period. This means the condition is being monitored, evaluated, treated, and has an impact on the current plan of care. The interdisciplinary documentation should include a clinical assessment with any present clinical indicators identified and the monitoring and effectiveness of any related care plan interventions. When supplements or other interventions are ordered to address malnutrition or the risk of malnutrition the diagnosis should be indicated on the MD order.
Contact Proactive for MDS consulting support
Written By:
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Senior Consultant
Proactive LTC Consulting
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