Improving physician documentation for malnutrition: A sustainable quality improvement initiative. 2023

Brittany E Levy, and Jennifer T Castle, and Wesley S Wilt, and Kelly Fedder, and Jeremy Riser, and Erin D Burke, and Jon S Hourigan, and Avinash S Bhakta
Graduate Medical Education, General Surgery Residency Program, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America.

This study compares documentation and reimbursement rates before and after provider education in nutritional status documentation. Our study aimed to evaluate accurate documentation of nutrition status between registered dietitian nutritionists and licensed independent practitioners before and after the implementation of a dietitian-led Nutrition-Focused Physical Exam intervention at an academic medical center in the southeastern US. ICD-10 codes identified patients from 10/1/2016-1/31/2018 with malnutrition. The percentage of patients with an appropriate diagnosis of malnutrition and reimbursement outcomes attributed to malnutrition documentation were calculated up to 24 months post-intervention. 528 patients were analyzed. Pre-intervention, 8.64% of patients had accurate documentation compared to 46.3% post-intervention. Post-intervention, 68 encounters coded for malnutrition resulted in an estimated $571,281 of additional reimbursement, sustained at 6, 12, 18, and 24 months. A multidisciplinary intervention improved physician documentation accuracy of malnutrition status and increased reimbursement rates.

UI MeSH Term Description Entries
D009752 Nutritional Status State of the body in relation to the consumption and utilization of nutrients. Nutrition Status,Status, Nutrition,Status, Nutritional
D010820 Physicians Individuals licensed to practice medicine. Physician
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D044342 Malnutrition An imbalanced nutritional status resulting from insufficient intake of nutrients to meet normal physiological requirement. Malnourishment,Nutritional Deficiency,Undernutrition,Malnourishments,Nutritional Deficiencies
D058996 Quality Improvement The attainment or process of attaining a new level of performance or quality. Improvement, Quality,Improvements, Quality,Quality Improvements
D064686 Nutritionists Persons specially trained in NUTRITION SCIENCES. Dieticians,Dietitians,Dietician,Dietitian,Nutritionist

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