Is there a definition for what qualifies as "clinical evaluation" for secondary diagnosis on inpatient encounters?
We had a cancer patient that had a diagnosis of severe protein calorie malnutrition listed as a diagnosis. No mention of weight loss, energy, loss of muscle mass, loss of subcutaneous fat, etc. No dietary consult or special dietary needs. Only stated severe malnutrition patient on regular diet. CDI is stating that should be enough and or at least if the doctor stated "stable" that this constitutes clinical evaluation because he addressed that the disease was stable. Our coders don't necessarily agree with that. Any help or guidance for what is a clinical evaluation would be appreciated.