If the dietician has a report citing the clinical indicators to support a malnutrition diagnosis and does identify the specificity such as severe protein calorie malnutrition can a yes/no query be utilized to see if the physician concurs or is that considered leading?
Looking forward to others thoughts
Cynthia Martin, BSN, RN, CCS, CDIP, CRC, CCDS, CEMC
AHIMA-Approved ICD-10 CM/PCS Trainer
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You can always add "unable to clinically determine" and "other" to your choices to make sure especially if is your only MCC.
Sharon Hekimian, RHIT CCS
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