PDPM Coding Questions – If a resident has a BMI greater than 40 but the MD has not documented “morbid obesity”, can we enter the Z code for BMI in the MDS and receive the NTA point?

by | Mar 17, 2020 | Coding, ICD.10, MDS, PDPM, Q&A

Q: If a resident has a BMI greater than 40 but the MD has not documented “morbid obesity”, can we enter the Z code for BMI in the MDS and receive the NTA point?   A: Yes, but as stated in the ICD-10-CM Code Book: BMI codes should only be assigned when the...

PDPM Coding Questions – If the dietitian completed a malnutrition assessment and the score indicates “at risk for malnutrition”, is the assessment considered sufficient supportive documentation to code Malnutrition in Section I if the physician were to review and sign the assessment form?

by | Mar 17, 2020 | Coding, Documentation, MDS, Medicare, PDPM, Q&A

Q: If the dietitian completed a malnutrition assessment and the score indicates “at risk for malnutrition”, is the assessment considered sufficient supportive documentation to code Malnutrition in Section I if the physician were to review and sign the assessment form?...

PDPM Coding Questions – The physician documented dehydration on the discharge summary, however the resident does not qualify for any of the 3 items listed in the RAI manual in J1550. Should dehydration be coded on the MDS?

by | Mar 4, 2020 | Coding, MDS, Medicare, PDPM, Physicians, Q&A

Q: The physician documented dehydration on the discharge summary, however, the resident does not qualify for any of the 3 items listed in the RAI manual in J1550. Should dehydration be coded on the MDS?   A: The coding for dehydration is based on the presence of...