Adult failure to thrive meaning12/13/2023 ![]() ![]() Is it acute confusion? Acute delirium? Metabolic encephalopathy? In coding terms, “altered mental status” has limited “value” when coded so what condition was the provider trying to convey? What was the significance of this finding?įor a patient admitted with a UTI, I might query to ask the provider if the patient is being treated for a local or systemic infection. Next, you need to look for clinical indicators to support a diagnosis to clarify the symptom of AMS. Just because someone is older and altered does not mean they need inpatient care. First, clarify is the patient usually altered or demented? If the patient has a history of dementia, you need to ask how this encounter is different from the patient’s baseline. Be sure the provider documents in terms of acuity, clarifying this is an “acute” AMS rather than their usual level of impairment. Often these conditions can be treated in the outpatient setting. You don’t want to be adversarial, but sometimes providers don’t document the complete picture so it can be helpful to ask why this patient needs an admission rather than outpatient/observation care. Let’s hope it isn’t just for nursing home placement as that really isn’t a valid reason for an inpatient admission so it will make your job more difficult.Īssuming there is something that distinguishes these inpatient cases from those who only need outpatient services, then you should review the record for any clinical indicators to support an undocumented diagnosis. Hopefully, your organization allows you to interact with providers so you could approach a helpful individual to gain insight into his/her thought process. Sometimes it is helpful to have a conversation to understand the physician’s perspective. Often providers have great justification for their admissions they just don’t realize how important it is for their thought process to be documented in the health record. Should I query for the underlying cause of the AMS?Ī: Talk with case management or utilization review team members to better understand why these patients were approved as inpatient. ![]() I am confused about how to identify the principle diagnosis in these cases, FTT or the UTI. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). Q: The majority of the admissions I am reviewing this week are for an elderly population.
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