Case of the Week
Weekly challenging patient scenarios to keep your IRF-PAI skills sharp and engage in peer discussion
Clinical Scenario
**Patient:** Margaret Thompson, 81-year-old female
**Admission Diagnosis:** Right hip fracture s/p ORIF
**Chief Complaint:** Fall at home 5 days ago, surgical repair completed
**Past Medical History:**
- Osteoporosis
- Hypertension
- Mild dementia
**Acute Hospital Course:**
- Right hip ORIF performed day 2 without complications
- Post-operative recovery unremarkable
- Cleared for IRF admission
**Physical Exam on IRF Admission:**
- Alert, oriented x2 (person, place)
- Weight: 98 lbs, Height: 5'4" (BMI 16.8)
- Appears frail, thin, with temporal wasting
- Skin: Dry, poor turgor, multiple ecchymoses on arms
- Albumin: 2.1 g/dL (drawn day before IRF admission)
- Prealbumin: 12 mg/dL
**Family Interview:**
"Mom has been losing weight for about 6 months. She forgets to eat meals and says food doesn't taste good anymore. Her clothes are all too big now. We've been worried but didn't know what to do."
**Nursing Assessment:**
- Poor appetite, leaves >50% of meals on tray
- Requires frequent cueing to eat
- Difficulty chewing, states dentures don't fit well
- No nausea or vomiting
**Question for Discussion:**
The acute hospital discharge summary lists only "right hip fracture" and "osteoporosis" as diagnoses. The IRF-PAI coordinator notes the low albumin but is unsure if malnutrition can be coded without physician documentation.
**What would you do?**
Learning Objectives
- Recognize clinical indicators of malnutrition beyond lab values
- Understand when physician queries are appropriate vs. leading
- Identify Tier 1 malnutrition criteria (E43 - severe protein-calorie malnutrition)
- Coordinate with interdisciplinary team for comprehensive documentation
Discussion Prompts
1. Should the coordinator query the physician for malnutrition? Why or why not?
2. What clinical indicators support a malnutrition diagnosis?
3. What tier would severe protein-calorie malnutrition be assigned?
4. How would you write the physician query to be compliant and effective?
5. What documentation should the RD and nursing team provide to support this diagnosis?
Share Your Thoughts
How would you handle this case? Share your approach, reasoning, and any questions you have.
New cases every Monday: Each week features a challenging real-world scenario designed to test your critical thinking and coding expertise.
Discussion-based learning: These cases don't have simple right/wrong answers. They're designed to spark discussion and help you think through complex coding decisions.
Expert analysis: Check back the following week to see expert commentary on the case and common approaches from other coordinators.
Continuing education: Engaging with these cases helps maintain your skills and stay current with coding challenges.