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: Risk adjustment indices are frequently used for hospital billing and reimbursements in the United States. Severity of illness (SOI) and risk of mortality (ROM) are two risk adjustment indices used in determining the APR-DRG, a classification system commonly used by insurers to determine hospital reimbursements. Recently, many health systems implemented AI-powered clinical documentation assistants [...]