December 12, 2017

Diagnosing and Documenting Malnutrition

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Dieticians’ findings must find their way into the medical record to achieve proper care and coding.

Diagnosing malnutrition is not diving for dollars.

Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty healing from trauma or surgery, or recovery from acute or chronic illnesses. It leaves patients vulnerable to secondary conditions like vitamin deficiencies and skin wounds.

Have you ever heard of the term “prehabilitation?” The concept was developed to prepare patients for elective orthopedic surgeries by giving them strength training to prevent injuries. It is now being expanded to other surgeries, to include cardiopulmonary training and optimizing nutritional status. It is meant to give patients reserves to withstand physical challenges. Surgeons are recognizing that nutrition in particular matters.

If I were a dietitian, I would be very irritated if I went through the effort of doing a thorough assessment of a patient’s nutritional status only to realize that the physician never looked at or acknowledged my findings or implemented my recommendations. If they do, but never document it, they don’t get credit for it, because it isn’t entered into the risk adjustment calculation.

Just like any other condition, the clinician should be making a diagnosis, giving clinical support, and doing something about it, if possible. A patient does not need to be prescribed appetite stimulants, but there should be some enteral or parenteral support.

If there is some degree of malnutrition, the dietitian should draw his or her conclusion. Giving a risk assessment is not the same as declaring, “this patient has moderate protein calorie malnutrition.”

Each organization should figure out a system to interface the dietitian’s consult with the clinician’s workflow so they can be made aware that the dietitian has accomplished the necessary tasks and is ready for the clinician to act on their recommendations. My old hospital system designed an electronic solution, and we eliminated many malnutrition queries, which up until then had constituted 20 percent of the total.

Providers often ask, what are the criteria for malnutrition? The most commonly referenced guidelines are found in the American Society for Parenteral and Enteral Nutrition’s (ASPEN’s) consensus statement from 2012.

My personal practice was to look for weight loss, subcutaneous fat loss, and muscle wasting, as well as decreased hand grip strength in the context of the underlying disease process. If I had the urge to use the terms “cachectic,” “emaciated,” “thin,” “skeletal,” or “failure to thrive,” I recognized that there was some degree of undernutrition. You can be obese or edematous and have malnutrition at the same time, but sometimes we must use baby steps in the emergency department.

My recommendation to you is to have providers document malnutrition when it is present, with the proper degree, to give clinical support, and to address it with appropriate therapy.
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk-Ten-Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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