February 29, 2016

Hungry for Accuracy on Malnutrition

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At this point, most clinical documentation improvement (CDI) programs are well-versed in the topic of malnutrition. New and old programs alike acknowledge that malnutrition is under-documented and that appropriately establishing this diagnosis for the patient can improve severity-of-illness metrics.

Malnutrition, however, seems to be like congestive heart failure (CHF) – the concept of specificity has been around forever, so why can’t we get it right? This article focuses on the established criteria for diagnosing and recognizing malnutrition in documentation, coding of malnutrition, and other impacts malnutrition can have (including on patient safety indicators, readmissions, and risk adjustment). 

Malnutrition Definitions 

Malnutrition is a broad term most commonly used to describe undernutrition. Humans need an adequate amount of calories, protein, and other nutrients to keep the body performing at peak efficiency for growth and maintenance. Illnesses can cause patients to take in too little or too much nutrition or interfere with the body’s ability to utilize the food that is consumed. Normally associated with children, malnutrition is becoming more prevalent in elderly populations, members of which are unable to properly care for themselves and who do not have the resources to obtain daily care or assistance.

Malnutrition is a major problem for hospitals. Up to one-third of patients are admitted in an already malnourished state – and if left untreated they will continue to experience a decline in their nutritional status. Another one-third of the hospitalized patient population will become malnourished during their stay. Malnutrition increases risk of pressure ulcers, delays wound healing, and increases incidence of infection. All of this translates to longer lengths of stay, more frequent readmissions, and higher levels of acuity, requiring increased care and resource consumption.

ASPEN Criteria

Prior to the publication of the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria, malnutrition frequently was evaluated using oral intake, weight change or loss, albumin, and prealbumin levels. Though these measures still can be used to support a query of malnutrition, most of these criteria are no longer considered acceptable as inclusion criteria for diagnosing malnutrition. One study found that “in critically ill patients, the serum prealbumin level did not respond sensitively to nutritional support. In addition, an increase in the prealbumin level does not indicate a better prognosis for critically ill patients.”  This has been previously discussed in depth by professionals in the CDI field. 

The ASPEN Malnutrition Consensus redefined adult malnutrition as undernutrition. The organization also changed the staging from mild, moderate, and severe to severe or non-severe. This, of course, clashes with the clarification of malnutrition as mild, moderate, or severe in the world of coding. The ASPEN severity of malnutrition scale is based on six characteristics, and the patient must meet two of the six:

  • Insufficient energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation that may sometimes mask weight loss
  • Diminished functional status as measured by hand grip strength

The other aspect is the idea of “context” in the new criteria. The three contexts are:

  • Chronic illness
  • Social/environmental circumstances
  • Acute illness or injury duration < three months

All of these contexts have varying parameters to better assess and specify malnutrition. A useful table to best utilize these criteria for severity can be found online

Coding of Malnutrition

The malnutrition codes are numerous; below we have listed the most frequent malnutrition diagnoses and codes along with their CC/MCC status and their individual SOI/ROM scores:

Diagnosis/Documentation

Code

CC or MCC?

SOI/ROM Score

Malnutrition – Unspecified

E46

CC

3/2

Malnutrition – Protein-calorie, Unspecified

E46

CC

3/2

Malnutrition – Protein-energy, Unspecified

E46

CC

3/2

Protein-calorie or Protein-energy Imbalance

E46

CC

3/2

Malnutrition – Mild protein-calorie

E441

CC

2/1

Malnutrition – Mild protein-energy

E441

CC

2/1

Malnutrition – Moderate protein-calorie

E440

CC

3/2

Malnutrition – Moderate protein-energy

E440

CC

3/2

Malnutrition – Severe protein-calorie

E43

CC

4/3

Malnutrition – Severe protein-energy

E43

CC

4/3

Starvation Edema

E43

CC

4/3

Nutritional Marasmus

E41

MCC

4/3

Emaciation (due to Malnutrition) – Unspecified (codes to Nutritional Marasmus)

E41

MCC

4/3

Malnutrition – Severe Protein-Calorie Intermediate Form (codes to Marasmic Kwashiorkor)*

E42

MCC

4/3

Kwashiorkor*

E40

MCC

4/3

Malignant Malnutrition*

E40

MCC

4/3

Malnutrition Following Gastrointestinal Surgery

K912

CC

3/1

Anorexia

R630

-

2/1

Weight loss

R634

-

1/1

Starvation (Initial Encounter)

T730XXA

-

1/1

Cachexia

R64

CC

2/3

Underweight with BMI 19 or Less

R636, Z681

CC

1/1, 1/1

Intestinal Absorption Unspecified

E7439

-

1/1

Failure to Thrive (Adult)

R627

-

2/1

Failure to Thrive (Child)

R6251

-

2/1

Failure to Thrive (Newborn)

P926

-

2/1

Retarded Development following protein-calorie malnutrition

E45

CC

3/1

Sequela of Protein-calorie Malnutrition

E640

CC

3/2

Code(s) that may be utilized in pediatric chart review are highlighted in pink.

 


Notice that “malnutrition, unspecified,” “protein-calorie malnutrition,” and “protein-energy malnutrition” are all synonymous when it comes to actual codes. Also notice that several other codes are synonymous as well. We have placed asterisks next to the above codes that should be approached with caution – coding these may result in an unwelcome audit, simply due to the fact that Kwashiorkor is unlikely to encounter in the United States (to be discussed below). And why does mild malnutrition have a lower SOI/ROM score than unspecified malnutrition? We don’t know.

Remember, the codes do not align with current severity recommended by ASPEN. This may change in the future. 

Tips for Querying and to Avoid Abuse and Fraud 

Our first tip is to not query just because a patient is underweight. As always, ensure that your patient meets clinical criteria for a diagnosis of malnutrition prior to querying. Otherwise, you put your facility at risk for abuse and fraud due to potential up-coding. Our second tip is to avoid documentation and coding of Kwashiorkor malnutrition at all costs. Kwashiorkor malnutrition usually only is seen in severely malnourished people or children in third-world or non-developed countries. It is very rare in the U.S. and not very likely to be occurring in your hospitalized patients. However, in the rare event that you do see this, make sure the documentation supports it. Hospitalized patients in the U.S. can (and frequently do) suffer from severe protein-calorie malnutrition or nutritional marasmus (though nutritional marasmus is infrequent).

As always, our last query tip is to educate your physicians and providers. Remember, the burden of documentation falls on them, and they often simply need educational sessions to remind them how important capturing malnutrition in the documentation can be to identify the severity of their patients.

Malnutrition – More than Just Severity – P4P and Readmissions 

As we’ve discussed numerous times, CDI is evolving. Yes, we are always trying to capture accurate documentation to portray the severity of our patients. At this time, however, documentation is more important than ever to capture even more for your hospital and your physicians. 

Per Dr. Pinson, “since coding and documentation impacts the P4P (pay-for-performance) outcome measures and rates based on comorbid conditions, and whether or not a condition is classified as a HAC (hospital-acquired condition), it is important to incorporate P4P initiatives into your existing CDI program … the five categories with the greatest impact on risk adjustment are metastatic cancer, lung and other severe cancers, quadriplegia, paraplegia, and malnutrition.” 

Malnutrition is also one of many diagnoses that can affect risk adjustment for readmissions. The patient’s severity of illness – based on comorbid conditions – will influence the risk adjustment. Those patients with higher SOI will have readmission rates adjusted downward. 

So, in conclusion, querying for, documenting, and finally coding of malnutrition have never been more important. Make sure that your CDI team understands the guidelines and recognizes the best way to query your providers. Also ensure that your hospital is compliant in not reporting out malnutrition unless your patient meets clinical criteria and is being treated for it. 

Rachel Mack, RN, MSN, CCDS, CDIP

Rachel Mack is a Senior Healthcare Consultant for Panacea Healthcare Solutions where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health and has worked in Clinical Documentation Improvement as a CDI Specialist and CDI Educator. She has written various articles and assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

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