Health Information Management

Q&A: Developing a query for malnutrition

CDI Strategies, July 21, 2011

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Q: Recently I have discussed the BMI and malnutrition status on patients with our Registered Dieticians (RD).  The question arose as to where our criteria came from.  I understand that the American Dietary Association sets the standards for the RDs, however, I don’t think the numbers that the RD uses and the CDI specialist use correlate with each other. 

The query/progress record that I use has the following check box information on it:
  • Severe Malnutrition (Albumin < 2.4)
  • Malnutrition (Albumin 2.4-3.0)
  • Severe Protein Calorie Malnutrition ( Albumin <2.4)
  • Protein Malnutrition (kwashiorkor)
  • Unspecified Protein Calorie Malnutrition
  • Cachexia
  • Marasmus
  • BMI = ______________
  • Unable to Determine
  • Other
We would like to make sure that the information and data we are using is current and correct. Can you please tell me who mandates the parameters used for the malnutrition diagnosis and are we correct in using the stated information? 
A:  I am hesitant to use albumin as a determinate of patient nutritional state, given it is a negative acute phase reactant that better signifies the patient’s inflammatory state. For that reason, I would not use these determinants in the query. Also, one needs to be very careful about how they list kwashiorkor, given the scrutiny that it has undergone. I note that mild or moderate malnutrition was excluded–this is dangerous since these conditions do have codes and clinical criteria for them. To leave them out, especially if the reason is that they are not CCs or MCCs, can make the query vulnerable for retrospective scrutiny. I would use the following sample query:
The following clinical indicators are in the medical record:
  • BMI _______
  • Ratio of BMI to IBW ________
  • Body Weight Status _____%
  • Change in Body Weight Status
  • Percentage change in body weight _______ over a period of ________
  • Dietary intake:
  • Albumin
  • Prealbumin
  • Documented physical findings:
  • Stress indicators:
Please indicate what diagnosis best correlates with these findings:
  • Cachexia
  • Nutritional Risk
  • Malnutrition, severity unknown
  • Malnutrition, mild
  • Malnutrition, moderate
  • Malnutrition, severe, not otherwise specified
  • Marasmus
  • Kwashiorkor – note – rare in the United States
  • Another medical diagnosis:
  • Other:
  • Cannot be determined.
The most credible source that a facility can use in clinically supporting a diagnosis of and the severity of malnutrition is the ADA/ASPEN. These two groups recently collaborated to develop criteria for adult malnutrition, which they discussed in a July 20, 2011 audio seminar entitled “Revisiting the Skeleton: New Characteristics and Criteria to Define Adult Malnutrition.”
Also, note that in the June, 2011, Minute to the Medical Staff (published in Medical Records Briefings) I listed criteria for adult malnutrition that I drew from a number of sources. 
Editor's Note: James Kennedy, MD, CCS, managing director at FTI Healthcare and a member of the ACDIS advisory board, answered this question. He may be reached at james.kennedy@ftihealthcare.comor 615/479-7021.

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