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RAI Compliance:

Beef Up Your Coding Accuracy and Care for Therapeutic Diets

Published on Mon Nov 07, 2011

Also get a tip on coding a mechanical diet.

In June 2011, CMS revised the MDS 3.0 Section K definition of a therapeutic diet to make it more clear, says Brenda Richardson, MA, RD, LD, CD. But there are still areas that can be confusing, cautions Richardson, a member of the American Dietetic Association-CMS workgroup to standardize and clarify some of the MDS 3.0 definitions.

Example: The "State Operations Manual indicates a mechanically altered diet meets the definition of a therapeutic diet," Richardson observes. By contrast, "the MDS 3.0 definition says 'a mechanically altered diet should not automatically be considered a therapeutic diet.'"

"You could code a mechanical diet as a therapeutic diet on the MDS 3.0," if it meets the RAI manual definition, Richardson says. The definition is as follows:

"A therapeutic diet is a diet intervention ordered by a health care practitioner as part of the treatment for a disease or clinical condition manifesting an altered nutritional status, to eliminate, decrease, or increase certain substances in the diet (e.g. sodium, potassium) (ADA, 2011)."

Thus, says Richardson, "you can't just assume because someone is on a mechanical or soft or dental diet (whatever the facility calls it), that it's part of their dietary intervention. We have some residents who just want a soft diet but they don't really have a clinical condition that requires it," she says.

Lack of standardization between the SOM and the MDS 3.0 "really creates a problem for providers in terms of knowing how to accurately code the MDS 3.0 and meet survey requirements," Richardson adds. "Facilities need to understand the difference [between] the interpretive guidance and MDS coding and be able to provide appropriate rationale for their decisions on how the MDS is coded."

Coding tip: "If a resident receives a mechanical diet that also qualifies as a therapeutic diet, then you would code both in Section K0500," advises Ron Orth, RN, RAC-MT, CPC, president of Clinical Reimbursement Solutions in Milwaukee, Wis. (See a picture of Section K0500 below.)

Another issue: "Generally, if a nursing home resident is on a renal diet or a 2 gm sodium diet related to kidney or cardiac disease, that's certainly a therapeutic diet," says Richardson. But "you could have a resident on a consistent carbohydrate diet," which would be coded as a therapeutic diet, if it's related to part of their treatment for diabetes, says Richardson. "No-one is going to argue about that," she adds. "But what if you have a younger older resident who says he or she just wants to eat healthy and be on consistent carbs for that reason? Is that therapeutic for them? There are still many questions out there" about this issue. "Yes, the diet is being modified -- however, is it a therapeutic diet for that individual?"

Richardson also cautions that "placing someone on a therapeutic diet could be a real negative for a person because they may not eat as well and start losing weight and not get adequate nutrients." As a result, the person could develop pressure ulcers, she adds. "It also affects their quality of life."

The registered dietitian's comprehensive nutritional assessment can determine the appropriateness of a therapeutic diet, says Richardson. "The family/resident input and involvement is very important," she stresses.

What the SOM says: "Sometimes, a resident or resident's representative decides to decline medically relevant dietary restrictions. In such circumstances, the resident, facility and practitioner collaborate to identify pertinent alternatives."

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