Health Information Management

Tip: Ensure malnutrition documentation and coding meet current clinical standards

CDI Strategies, February 28, 2013

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Last March a Maryland hospital agreed to pay nearly $800,000 to resolve allegations that its employees used leading queries to add malnutrition as a secondary diagnosis.

New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics represents a consensus statement of the American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN). The guidelines indicate that malnutrition should be diagnosed when at least two or more of the following six characteristics are identified:
  1. Insufficient energy intake
  2. Weight loss
  3. Loss of muscle mass
  4. Loss of subcutaneous fat
  5. Localized or generalized fluid accumulation that may sometimes mask weight loss
  6. Diminished functional status as measured by hand grip strength
It further states that malnutrition should be considered within the context of an acute illness or injury, a chronic illness, or social or environmental circumstances to determine whether malnutrition is present and whether it’s severe or non-severe (moderate).
On March 14, 1–2:30 p.m., eastern, former ACDIS Advisory Board member James S. Kennedy, MD, CCS, will outline the changes to the clinical landscape and discuss the coding rules governing malnutrition code assignment. He will be joined by Joann Agin, RHIT, CCDS, Regional Manager, Data Quality, Carondelet Health, Kansas City, Mo., and Mindy Hamilton a registered dietitian. Agin and Hamilton worked together to create a comprehensive plan for capturing malnutrition documentation. To learn more about the program, visit the CDI Marketplace.
Editor’s note: Portions of this tip were included in the July 2012 edition of the CDI Journal.

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