Health Information Management

Q&A: Coding emaciation without documented malnutrituion

HIM-HIPAA Insider, October 11, 2011

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Q: A physician documents emaciation without noting malnutrition. ICD-9-CM indexes emaciation to ICD-9-CM code 261 (nutritional marasmus). Must the physician document malnutrition, or is documentation of emaciation sufficient to assign ICD-9-CM code 261?

A: A review of ICD-9-CM code 261 in the tabular index reveals the following narratives: nutritional atrophy, severe calorie deficiency, and severe malnutrition not otherwise specified. Therefore, because the category includes malnutrition, documentation of emaciation is sufficient to assign ICD-9-CM code 261.
 
Editor’s note: Sandra L. Sillman, RHIT, PAHM, a DRG coordinator at Henry Ford Hospital & Health Network in Detroit, answered the previous question in the October issue of Briefings on Coding Compliance Strategies.



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