Malnutrition is a significant health concern for many patients that are treated in both inpatient and outpatient settings. At least half of all hospitalized patients are malnourished. Malnutrition increases the patient’s recovery time, length of stay, and resources needed for treatment. Nutrition deficits can lead to muscle loss, weakness, pressure ulcers, infections, delayed infection and wound healing, increase fall risk, and possible hospital readmissions.
Reimbursement to cover the cost of resources for treating malnutrition will only be received if the malnutrition is identified and diagnosed.
Complete and accurate code assignment is one way to ensure reimbursement for the costs incurred from treating the patient’s malnutrition. Failure to assign codes for diagnoses that are CCs or MCCs may mean assignment of a DRG and does not reflect the patient’s severity of illness and resources required for treatment of the patient.
Recognizing query opportunities requires understanding how malnutrition affects the patient and the patient’s care, the common causes of malnutrition, and its consequences.
What is Malnutrition?
The American Society for Parenteral and Enteral Nutrition/Academy of Nutrition and Dietetics Malnutrition Consensus Statement (ASPEN) defines malnutrition as "any nutritional imbalance”.
The National Library of Medicine (NIH) describes malnutrition as a “deficiency or excess imbalance of a wide range of nutrients resulting in a measurable adverse effect on body composition, function and clinical outcome.”
Causes:
The most common causes of malnutrition are:
- Chronic Disease- Chronic diseases such as cancer, Crohn’s, diabetes, HIV etc.
- Acute Illness or Injury- Sepsis, major surgery, multi-system trauma, intubation, prolonged vomiting
- Poverty and Food Insecurity- Lack of financial resources can limit access to nutritious food
- Aging- Older adults are more prone due to decreased appetite, physical limitations and increased risk of chronic disease
- Pregnancy, Breastfeeding and Infancy- Increased requirements for nutrient intake to support growth and development
- Medications- Including chemotherapy, antibiotics, PPI’S, etc.
- Mental Health Conditions- Anorexia nervosa, depression and dementia can negatively impact appetite and food intake
- Alcohol and Drug Dependency- Substance abuse can interfere with nutrient absorption
- Social Isolation and Mobility Problems- Difficulty for individuals to access food, prepare meals or maintain a healthy appetite
- Digestive Problems- Conditions such as Dysphagia, Malabsorption or Genetic Abnormalities can hinder the body’s ability to absorb nutrients from food
- Post Surgical Status – Altered Anatomy alters how food is digested, and nutrients are absorbed specifically vitamin B12, iron and calcium may not be absorbed in the bypassed portion of the small intestine Unsuitable
- Dietary Choices – Poor dietary choices can lead to insufficient vitamin and mineral intake
- Wound Healing- Wound healing requires increased nutrient intake
- Lack of Knowledge- Limited understanding of healthy eating can lead to poor dietary choices
What are the Consequences of Malnutrition?
Malnutrition can affect the function and recovery of every organ system in a patient.
- Muscle function- often the most obvious sign of malnutrition- muscle function declines prior to changes in muscle mass
- Cardio-respiratory function- cardiac muscle mass is decreased and can have an impact on renal perfusion and glomerular filtration rate
- Gastrointestinal function– results in changes to pancreatic exocrine function, blood flow in the intestines, loss of ability of colon to reabsorb water and electrolytes
- Wound healing/Immunity- can result in delayed wound healing and increased the risk of infections
- Psychosocial– can result in psychosocial effects including apathy, depression, anxiety and self-neglect.
How is Malnutrition Treated?
Treating severe malnutrition, especially in children, often involves a multi-step process by correcting nutrient deficiencies, correcting electrolyte imbalances, treating medical complications such as infections and wound healing, and gradually increasing caloric intake.
Inpatient Treatment (Hospital):
- Initial Stabilization: Addressing immediate imbalances like hypoglycemia, hypothermia, dehydration, and infections.
- Monitoring for Medical Complications: Severe malnutrition can lead to multiple medical complications, which include infections such as sepsis or pneumonia, severe anemia, and dehydration.
- TPN (total parenteral nutrition) and enteral (G-tube of NG feeding tube)
- Therapeutic Foods: Specialized therapeutic foods like F-75 (a high-energy, high-protein milk) and ready-to-use therapeutic food (RUTF)
- Micronutrient Supplementation: Correcting deficiencies in vitamins, minerals (especially zinc and vitamin A), and other micronutrients.
- Gradual Feeding: Malnourished individuals cannot be refed abruptly and would be treated utilizing a gradual approach to increase caloric intake preventing complications like refeeding syndrome.
- Monitoring: Regular monitoring of weight, height, and other vital signs to track progress and make adjustments to treatment as needed.
What are the Clinical Indicators for Malnutrition?
The ASPEN criteria are a commonly accepted set of guidelines for establishing the presence of malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) is another. The ASPEN criteria will be used for the purpose of this article.
The ASPEN criteria evaluate the presence and severity of:
- Energy intake
- Weight loss
- Muscle mass loss
- Body fat loss
- Edema
- Reduced grip strength
The value required for each criterion to arrive at a diagnosis of malnutrition is evaluated in the context of specific circumstances including:
- Acute illness/injury
- Chronic illness
- Social and environmental circumstances
ASPEN Criteria
Malnutrition is indicated by the presence of one or more of 3 clinical contexts, and 2 or more of 6 clinical characteristics.
Clinical Contexts:
- Aute illness or injury (duration < 3 months)
- Chronic illness (duration of >= 3 months)-cancer, HIV, malabsorption, dysphagia, ESRD
- Social/environmental circumstances
Clinical Characteristics:
- 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
Each clinical characteristic has specific lab values or criteria that can be used to measure malnutrition’s severity.
Severe malnutrition in an acute care setting:
- Energy intake: less than (<) 50% estimates energy requirement for greater than (>) 5 days
- Weight loss (% of body weight):
- >2% in one week; or
- >5% in one month; or
- >7.5% in three months
- Muscle mass loss: moderate
- Body fat loss: moderate
- Edema masking weight loss: moderate to severe
- Reduced grip strength: measurably reduced
Severe malnutrition in the setting of chronic disease:
- Energy intake: less than (<) 75% estimates energy requirement for greater than (>) 1 month
- Weight loss (% of body weight):
- >5% in one month; or
- >7.5% in three months; or
- >10% in six months
- >20% in a year
- Muscle mass loss: severe
- Body fat loss: severe
- Edema masking weight loss: severe
- Reduced grip strength: measurably reduced
Severe malnutrition secondary to social circumstances:
- Energy intake: less than (<) 50% estimates energy requirement for greater than (>) 1 month
- Weight loss (% of body weight):
- >5% in one month; or
- >7.5% in three months; or
- >10% in six months
- >20% in a year
- Muscle mass loss: severe
- Body fat loss: severe
- Edema masking weight loss: severe
- Reduced grip strength: measurably reduced
How Do You Know When To Query For Malnutrition and Its Severity?
A query for malnutrition is appropriate if documentation supports:
- the patient has met ASPEN criteria for
- 1 or more of 3 clinical contexts
- 2 or more of 6 clinical characteristics
- the patient has an acute or chronic illness or social/environmental circumstances
- treatment/nourishment was provided to the patient
Case Examples
Example 1:
80-year-old male with dementia was admitted for sepsis due to pneumonia. The patient had a stroke 4 months prior with resulting dysphagia resulting in an unintended weight loss of 6 pounds. The patient’s BMI was 20 on admission. A dietician was consulted with the following findings:
Nutrition Diagnosis: moderate malnutrition (non-severe)
Weight loss in the past 6 months; Intake <50% of baseline x> /=1-month, moderate muscle and fat loss. Loss of 6 pounds in the last 4 months
Physical findings: Muscle loss; Loss of subcutaneous fat (shoulders, triceps-moderate); BMI 20.07
Patient was supplemented with Ensure Plus and electrolytes replenished though PIV.
The diagnosis of malnutrition was not documented for the encounter other than by the dietician consultation.
In this encounter, a query is appropriate to confirm the severity of the diagnosis of malnutrition as moderate, as the patient met non-severe (moderate) ASPEN criteria for malnutrition, has an acute illness with loss of muscle mass and subcutaneous fat and a chronic condition dysphagia from prior stroke. Nutrition was supplemented with Ensure and electrolytes were replenished.
Query Example:
Dietary consultation has documented the following in the medical record regarding this patient’s nutritional status:
- BMI 20
- Muscle loss; Loss of subcutaneous fat (shoulders, triceps-moderate)
- Energy intake of < 75% over the past 4 months
- Patient admitted with sepsis due to pneumonia and has residual dysphagia from stroke 4 months prior
- Unintended weight loss of 6 pounds over 4 months
- Nutrition consultation was performed with the finding of moderate malnutrition
- Nutritional supplementation: Ensure Plus due to dysphagia, electrolytes replenished via PIV
Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions may be causing these findings:
- Malnutrition (please specify severity, if known: mild, moderate)
*Severe malnutrition would not be included as a choice as the patient did not meet severe malnutrition per ASPEN criteria
- Weight loss only
- Underweight only
- Nutritional deficiency (please specify)
- Another cause(s): please specify
- None of the above / Not applicable
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that your response should necessarily be any one particular condition listed, in which case please indicate your alternative diagnosis.
There are cases where the diagnosis of severe malnutrition is documented by a physician, but the patient does not meet ASPEN criteria for severe malnutrition. A clinical validation query would be necessary to confirm/clarify the diagnosis for proper reporting to prevent a potential denial.
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Example 2:
67-year-old patient was admitted for acute kidney injury (AKI) and dehydration. The patient was noted to be depressed after losing his wife 2 years ago. The patient had lost interest in eating or drinking after the loss of this wife. The patient lost 35 pounds over the last year and a half but noticeably more recently. Several providers documented severe malnutrition in multiple progress notes. The patient was treated with Ensure Plus TID with meals. AKI and dehydration were treated with IV fluids. A dietician consultation was completed with the findings below:
Nutrition Assessment: Energy intake <75% for > 1month, moderate fat and muscle loss; 5’10, 165 lbs. BMI 23.7. Pt reports wt. loss of 35 pounds over past 1.5 years d/t depression. Poor appetite.
Nutrition/MD Diagnosis: Moderate protein-calorie malnutrition.
In this encounter, the diagnosis of severe Malnutrition is not clinically supported and does not meet ASPEN criteria for severe malnutrition. A clinical validation query is necessary for proper reporting of the patient’s diagnosis.
Clinical Validation Query Example:
The diagnosis of severe Malnutrition was documented on progress notes (include dates)
The diagnosis of moderate malnutrition was documented on the dietician consultation
- BMI 23.7
- Muscle loss; Loss of subcutaneous fat
- Energy intake of < 75% for > 1 month
- Patient admitted for AKI and dehydration due to poor appetite after the loss of his wife
- Unintended weight loss of 35 pounds over 18 months
- Nutrition Consultation was performed with the finding of moderate malnutrition
- Nutritional Supplementation: Ensure Plus TID
Based on the clinical indicators above, can you please clarify in the medical record whether:
- Severe malnutrition is not confirmed / Patient is being treated for moderate malnutrition.
- Severe malnutrition is confirmed (please document additional supporting information or mitigating factors)
- Other explanation of clinical findings (please specify)
- None of the above/Unknown
In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that your response should necessarily be any one particular condition listed, in which case please indicate your alternative diagnosis.
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References
- Coding Clinic 2013 First Quarter, p. 13: Emaciated/Emaciation without Documented Malnutrition.
- Coding Clinic 2017 Third Quarter, p. 24: Emaciation and Malnutrition
- Coding Clinic 2017 Third Quarter, p. 25: Severe Malnutrition
- Coding Clinic 2020 First Quarter, p. 4: Q&A Regarding Coding of Malnutrition
- Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition
- NIH: Malnutrition: causes and consequences
- ACDIS Q&A Documenting and coding severe malnutrition
- Malnutrition Syndromes: A Conundrum vs Continuum. J Parenter Enteral Nutr 2009; 33(6):710-716.
- Drug-Induced Nutrient Depletions: What Pharmacists Need to Know
- Medications and their Potential to Cause Increase 'Malnutrition'
- The Solution to Severe Malnutrition Denials: Document the Treatment! Pinson and Tang November 2020
- Coding for Malnutrition in the Adult Patient: What the Physician Needs to Know
- Query Templates: Pinson & Tang CDI Pocket Guide
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