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?



A dietician can identify and treat malnutrition, but the NTA comorbidity requires a physician’s diagnosis. According to the RAI, Section I: Active Diagnoses in the Last 7 days:

The disease conditions in this section 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… Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period



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Blog by Eleisha Wilkes, RN, RAC-CTA , Proactive Medical Review

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