← Work Queue|COLEMAN, MARGARET82FMRN 9000013712 · Acct 402000030618 · Anaheim GMCAdmit 07/09/2026 · Disch 07/12/2026
AI ScreenedNguyen, Peter MD (Hospitalist) · 07/09/2026 21:14
CHIEF COMPLAINT: Failure to thrive, generalized weakness.
HISTORY OF PRESENT ILLNESS: 82-year-old female brought in from home by her daughter for progressive weakness and poor oral intake. Daughter reports the patient has been eating less than half of her meals for the past two months and has become increasingly withdrawn. Reported weight loss of approximately 14 lbs over the last 3 months (measured 128 lbs in April, 114 lbs today).
PAST MEDICAL HISTORY: Unspecified dementia without behavioral disturbance. Hypertension, well controlled. Osteoarthritis.
PHYSICAL EXAM: Elderly female, appears frail. Temporal wasting noted. Marked loss of subcutaneous fat at triceps and mid-axillary line. Interosseous muscle wasting in both hands. No peripheral edema. Neuro exam nonfocal.
ASSESSMENT AND PLAN: 1) Failure to thrive: admit for workup, nutrition consult ordered. 2) Dementia: continue home regimen. 3) DVT prophylaxis.
AI screening summary
Chart documentation supports severe protein-calorie malnutrition (E43) under ASPEN criteria with provider concurrence. Adding E43 as an MCC regroups the encounter from DRG 641 to DRG 640.
Severe Malnutrition (Chronic Illness)ASPEN/AND 2012 characteristics · 2 or more characteristics required
4/6 metMet
- MetEnergy intake <75% of estimated requirement for >=1 monthRD documented intake below 50% of requirement for more than 1 month.
- MetWeight loss >7.5% in 3 months10.9% loss over 3 months documented by RD; corroborated in H&P.
- MetSevere subcutaneous fat lossSevere fat loss at triceps documented on RD exam; also noted in H&P.
- MetSevere muscle mass lossTemporal and interosseous wasting documented by MD and RD.
- Not metFluid accumulation masking weight lossRD documented no fluid accumulation.
- InsufficientReduced handgrip strengthNot assessed during this admission.
Code suggestionsCoder decision required on every line
E43MCCNEWUnspecified severe protein-calorie malnutritionconf 94%
Dietitian documented severe protein-calorie malnutrition with 4 of 6 ASPEN characteristics; attending physician concurred in the Day 2 progress note, satisfying provider documentation requirements.
R62.7PrincipalAdult failure to thriveconf 91%
Documented chief complaint and admission focus. Retained as principal diagnosis; sequencing with E43 reviewed under coding guidelines.
Z68.1SecondaryNEWBody mass index (BMI) 19.9 or less, adultconf 88%
RD documented BMI 19.6 on admission. Replaces Z68.21 (BMI 21.0-21.9) coded from an earlier outpatient value.
F03.90SecondaryUnspecified dementia without behavioral disturbanceconf 86%
Documented in PMH and active problem list.
DRG and estimated reimbursement (Medicare inpatient)
As coded
DRG 641wt 0.7782
Misc disorders of nutrition, metabolism, fluids and electrolytes without MCC
$4,738.83
With E43 (if accepted)
DRG 640wt 1.0862
Misc disorders of nutrition, metabolism, fluids and electrolytes with MCC
$6,614.39
Potential reimbursement delta+$1,875.56
Payment = DRG weight x blended base rate ($6,089.48)