These diagnoses are often missed since they are commonly only seen in the Physical Exam or Review of Systems portion of a record. There are often ‘knee-jerk’ reactions that can lead a coder to investigate further if a patient may have these diagnoses.
What to look for
Cachexia is commonly seen in patients who have AIDS, cancer, or other advanced heart or lung disease. You will often see a lack of appetite, fatigue, low BMI, and malnutrition. Look for nutritional consults and a PEG tube in the documentation to trigger the search for cachexia in the documentation.
Why is this so important?
Cachexia is a diagnosis that can affect reimbursement for both Inpatient and Risk Adjustment. Don’t miss it!