Background: Accurate coding is paramount to hospital revenue generation and is often supported by a clinical documentation integrity (CDI) team made up of registered nurses and non-clinical coding personnel. Physician-led coding initiatives have demonstrated improvement in case-mix index and clinical documentation. We hypothesized that physician integration into CDI would result in a more robust improvement [...]

Background: Many hospitalized adults arrive with pre-existing malnutrition, which is associated with high risk of adverse outcomes. As such, malnutrition is a common variable in cost and quality risk adjustment models based on hospital discharge diagnosis codes. Hospital dietitians assess patients for malnutrition and generally document the details of their evaluations. However, coding professionals cannot [...]

Background: Malnutrition is a significant indicator for illness severity and expected mortality. Prior to any process improvement interventions in 2014, only 4.7% of UNMH inpatients were diagnosed with malnutrition at discharge, much lower than the published national inpatient prevalence of 20-50%. Given the relatively high level of poverty in NM, we believe these lower rates [...]