Health Information Management

New malnutrition criteria could help ensure consistent coding

JustCoding News: Inpatient, July 18, 2012

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New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria.

New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics represent a consensus statement of the American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN). The Academy and ASPEN both advocate for provider use of a standardized set of diagnostic characteristics to identify and document adult malnutrition, says Jane White, professor emeritus in the department of family medicine at the University of Tennessee in Knoxville. White also serves as chair of the Academy's adult malnutrition work group.

The Academy and ASPEN state malnutrition should be diagnosed when providers identify at least two or more of the following six 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
Providers must assess these six characteristics in the context of an acute illness or injury, a chronic illness, or a social or environmental circumstances to determine if malnutrition is present and whether it's severe or non-severe (moderate). The article provides a table with more detailed clinical criteria to which providers can refer when documenting severity levels for malnutrition.

The Academy and ASPEN have asked the National Center for Health Statistics (NCHS) to adopt ICD-9-CM malnutrition codes that use etiological-based nomenclature, says White. If adopted, the ­ICD-9-CM codes will better reflect the clinical presentations that providers encounter when assessing malnutrition, she says.

Don't fall into a compliance trap

This suggested change comes as good news for coders and ­providers who continue to struggle with third-party audits of CC and MCC conditions, including malnutrition, says James S. Kennedy, MD, CCS, CDIP, managing ­director at FTI Consulting in Atlanta.

One need not look far to discover the case involving a Maryland hospital whose employees allegedly used leading queries to add malnutrition as a secondary diagnosis. Good Samaritan Hospital in Baltimore denied the accusations, but agreed to pay nearly $800,000 to resolve the False Claims Act violation allegations, according to a March 28 press release from the U.S. Department of Justice.

"If patients had truly had malnutrition, it wouldn't have been as much of an issue," says Kennedy. He attributes incorrect malnutrition coding to a lack of consistent clinical criteria and says that many CDI programs also incorrectly define malnutrition solely on low albumin or prealbumin levels.

Another case involved Shasta Regional ­Medical ­Center in Redding, Calif., which allegedly billed ­Medicare for treatment of more than 1,000 cases of kwashiorkor over a two-year period, according to a California Watch analysis of state health data. ­California Watch describes itself as "the largest group of journalists dedicated to investigative reporting in the state" on its website.

Kwashiorkor, a form of malnutrition that occurs when a diet lacks sufficient protein, is very rare in the United States, and is not something that coders encounter ­frequently, says Alice Zentner, RHIA, director of ­auditing and education at TrustHCS in Springfield, Mo. Physicians must specifically document the term "kwashiorkor" for coders to report it, she says.

Although the ICD-9-CM index instructs coders to report code 260 (kwashiorkor) for unspecified protein malnutrition, Coding Clinic, Third Quarter 2009, p. 6, discourages assignment of this code when physicians document moderate or mild protein malnutrition, says Kennedy.

Rely on helpful strategies

Coders should remember and use the following strategies.

Don't always assume documentation is ­correct.
It may seem counterintuitive, but coders should question a diagnosis when it appears that no clinical evidence supports it, says Kennedy. For example, physicians often incorrectly diagnose malnutrition based solely on a low albumin or prealbumin, he says. Third-party auditors will challenge this diagnosis, and coders should also question it, he says.
Coders must ensure that physicians document and treat protein-calorie ­malnutrition-an MCC, says Zentner. "If that code is on a record, it's certainly a red flag for a RAC to audit," she says.

Malnutrition must also meet the definition of a reportable secondary diagnosis, says Zentner. Coders should also remember not to report cachexia, a wasting syndrome, as malnutrition. Instead, cachexia is denoted by a symptom code (799.4), she says.

Hospitals should develop policies that explain how coders should address inconsistent and unreliable diagnoses, says Kennedy. Unreliable diagnoses are ones that don't meet reasonable criteria established by the medical staff. Once identified, these diagnoses should be vetted by a coding supervisor, physician advisor, or CDI specialist, he says.

Beware of leading queries.
A physician often does not document a malnutrition diagnosis when a patient does, ­indeed, have the condition. However, as the Good Samaritan Hospital case demonstrates, coders must be certain that they don't lead physicians when requesting clarification, says Kennedy. "We are allowed, as coders, to ask providers for the clinical significance of abnormal labs or clinical findings," he says. Consider the ­following query based on the new criteria from the Academy and ASPEN:

The following clinical indicators are in the medical record:
  • Current BMI _____
  • Stress indicator - Acute illness - Chronic illness - Social
  • Energy intake over the previous ___ days ___%
  • Amount of weight loss over ___ days ____%
  • Loss of subcutaneous fat (circled)
  • Loss of muscle mass (circled)
  • Fluid accumulation (circled)
  • Measurably reduced grip strength present - Yes - No
Please indicate what diagnosis best correlates with these findings:
  • Cachexia without malnutrition
  • Nutritional risk without malnutrition
  • Malnutrition, severity unknown
  • Malnutrition, non-severe (moderate)
  • Malnutrition, severe, not otherwise specified
  • Marasmus - A specified severe protein-calorie malnutrition
  • Kwashiorkor - A specified severe protein malnutrition
  • Another medical diagnosis
  • Other (please specify)
  • Cannot be determined
Other clinical evidence in the record that might suggest malnutrition includes chronic disease, insufficient intake (pre- or postoperatively), infection, malabsorption, muscle wasting, poor wound healing, or lethargy, says Zentner.

Work with CDI specialists.
Ask CDI specialists to educate physicians about malnutrition clinical indicators, advises Kennedy. Also advocate for pre-discharge queries. "The query for malnutrition is really best done in a pre-discharge environment in collaboration with dietitians, nutritional teams, and the CDI team," he says.

Editor’s note: This article originally appeared in the July issue of
Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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