Case Study: Automate Malnutrition Documentation to Accurately Reflect Risk and Improve Documentation and Quality Metrics

Launch date: July 1, 2024

Presented by:
Trisch Dasch, BSN, RN, CCDS
Kevin O’Malley, MD
Dianne Hanna, MBA, RHIA, CCS

Between 2016 and 2019 at Johns Hopkins Hospital, as many as 20–65% of patients with malnutrition confirmed by a registered dietitian were not assigned a malnutrition diagnosis code at the time of final health information management coding. In response, a multidisciplinary team convened. Learn how this team performed intensive manual chart reviews, deployed education to providers and coders, and created an electronic malnutrition documentation tool to more accurately and efficiently represent and report the patient population with malnutrition. This initiative also resulted in improved support for malnutrition to be reported as a secondary diagnosis and decreased query rates.

This session was presented at the 2024 ACDIS national conference in the Clinical & Coding track. It is also available for purchase as part of the 2024 ACDIS Encore: Clinical & Coding Online" virtual event, slated for August 2024.

At the conclusion of this program, participants will be able to:

• Describe, in broad terms, why malnutrition is clinically relevant, diagnosed, and treated.
• Describe why accurate malnutrition documentation is essential for health institutions to describe patient complexity.
• Outline how a team-based and informatics-powered documentation support strategy can help to both support clinical care and accurate malnutrition documentation.

Agenda

• Background information
• Prevalence, clinical significance, diagnosis, and treatment
• The problem
• Inaccurate documentation > inaccurate risk adjustment
• Our solution
• Team-based, data-powered documentation support

Who Should Listen?

• CDI directors and managers
• CDI staff
• HIM/coding directors and managers
• Coding staff
• Revenue integrity directors and managers
• Revenue integrity staff
• Denials and appeals staff
• Quality professionals

Meet the Speaker

Trish Dasch, BSN, RN, CCDS, is the director of clinical documentation excellence at the Johns Hopkins Health System. In 2008, she was introduced to CDI and has reported to several departments over the years (HIM, QI, and Finance). Dasch is a certified clinical documentation specialist, past vice president of the Maryland ACDIS local chapter, and is currently serving as a member of the ACDIS Leadership Council and the ACDIS Mastermind.

Diane Hanna, MBA, RHIA, CCS, is currently the director of inpatient coding at the Johns Hopkins Health Care System. She has 40 years of health information management experience in large and small academic centers, community hospitals, children's hospitals, and the Veterans Administration. In addition to HIM, her roles include management of utilization management, quality assurance, medical staff services, and teaching.

Kevin O’Malley, MD, is an assistant professor in the department of medicine of the Johns Hopkins University School of Medicine, and a hospitalist at the Johns Hopkins Hospital. His areas of focus are clinical medicine, clinical informatics, and education.

Continuing Education

NOTE: The ability to claim these credits for this webinar expires on June 30, 2025

ACDIS
This program has been approved for 1 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist certification, offered as a service of the Association of Clinical Documentation Integrity Specialists (ACDIS).

AHIMA
This program has been approved for 1 continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.

ANCC
HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

This educational activity for 1 nursing contact hours is provided by HCPro.

NAHRI
This program has been approved for 1 continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI), offered as a service of the National Association of Healthcare Revenue Integrity (NAHRI).