Q: Can facilities create a policy that allows coders to pull documentation from a dietician’s note if it is co-signed by the provider?
A: Based on Coding Clinic’s answer in 1Q 2020, page 4, yes. However, Haugen recommends facilities not consider this best practice and require coders pull this information from a provider’s written narrative
Q: Are there different ASPEN criteria for children?
A: Yes. Pediatric ASPEN criteria are developed for children between the ages of 1 month to 18 years. Over the age of 18, the adult ASPEN criteria are used.
Q: Since documentation of treatment of malnutrition is so important, what do you do if a patient is on palliative care and the family is refusing treatment for malnutrition? Can a diagnosis for severe malnutrition still be documented and reported if there is no treatment?
A: Haugen recommends the physician document in the written narrative the treatment that was recommended as well as the family wishes as to why the treatment was not carried out (i.e. palliative care).
Terri Reid, CCS, CCS-P, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer
Senior Coding Quality Auditor
Terri comes to Haugen Group with 20+ years of health information management experience in coding, auditing, and education. She began her career coding emergency room records and wound care records where she helped develop coding and E/M protocols and met with the providers to help them improve their documentation. Terri transitioned to an auditing role when she realized how much she enjoyed sharing her coding knowledge and experiences with other coders to help improve their skills and confidence. Terri brings her expertise in coding and auditing to the Haugen Consulting Group, having worked in previous roles leading and performing inpatient and outpatient coding audits. She is passionate about learning new medical technology and how the disease process affects illnesses.