The Registered Dietitian in my building has documented malnutrition on a new admission. I want to ensure I receive the 1 NTA point for malnutrition. Can I use the Dietician’s documentation to code Malnutrition in I5600? Will coding malnutrition in I5600 capture the NTA point?
To be able to code a diagnosis in Section I of the MDS, 2 criteria must be met:
- A physician must have documented the diagnosis in the last 60 days; and
- The diagnosis must have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7 day look back period (pg I-7 RAI Manual).
I suggest meeting with the IDT to review new admissions prior to the ARD of the assessment and completing a thorough review of the resident medical record. Consider the existing supporting documentation and query the physician for possible new diagnosis as necessary.
Chapter 6 page 30-31 of the RAI Manual provides Table 16, a listing of the condition/extensive services impacting the NTA Comorbidity score calculation. Table 16 also provides the MDS items used to capture the NTA point. For malnutrition, I5600 will provide the NTA point.
- Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual