Il est un fait que le guide PMSI MCO est à la fois strict sur certaines pratiques de codage et flou quand il s’agit d’apporter des précisions utiles au choix finale du bon code !
Pour l’exemple: la malnutrition ( dont vous retrouvez un précédent article ici)
La CIM10 propose 4 codes de malnutrition (hormis les situations extrêmes rares en métropole) : le guide permet de coder la dénutrition et la dénutrition sévère. Quand on sait les enjeux de la précision sur la valeur finale du GHS … on a intérêt de chercher à décrire mieux . Ce d’autant qu’un clinicien peut averti décrira parfois un état de dénutrition sévère sur la seule prescription d’un complément alimentaire ( terme médical rédigé de manière « pifométrique ») …
La société francophone de nutrition clinique et métabolique propose sur son site dans sa rubrique formation/OUTIL/arbre décisionnel du soin nutritionnel
Vous y trouverez enfin la définition d’une dénutrition modérée ! A rajouter à la fin de votre guide de codage …
Remerciements à l’équipe du DIM du CH Belfort – Montbéliard pour ce tuyau très utile !
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