Health Information Management

Q&A: Review clinical criteria for malnutrition

CDI Strategies, November 21, 2013

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Q: I am part of a fairly new CDI department trying to amp-up our physician education/guidelines. To that end, I have been reviewing the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) recent guidelines for malnutrition. The part that is confusing me is that it does not address mild malnutrition. If the physician documents malnutrition but the patient does not meet two out of six criteria (or more) required by the new guidelines, should we not code for malnutrition?

A: Determining when to query for a malnutrition diagnosis can be very tricky. First, make sure the malnutrition meets the definition of a secondary diagnosis—i.e., is there evaluation, monitoring, treatment, increased nursing care and/or increased length of stay.  Although coding guidelines state that only one of these criteria needs to be met in order for a diagnosis to be considered a secondary diagnosis, there are some diagnoses that I recommend always have supportive treatment—malnutrition is one of them. I recommend you make sure there is some treatment associated with any malnutrition diagnosis and that the type of treatment supports the severity of the malnutrition.

Secondly, determine if the clinical evidence supports the diagnosis of malnutrition and if so, to what specificity. Clinical indicators are important in two different types of situations—when clinical indicators for a condition are present but the condition itself is not documented, and when the condition is documented but the clinical indicators are missing.

In other words, in the first type of situation we are trying to see if the diagnosis of malnutrition is applicable to this patient during this episode of care.  Since auditors target malnutrition, CDI/coders need to use very strict criteria before querying—it should obvious to anyone reading the health record that the patient has malnutrition before you query for it.

In the second type of situation, the definition of malnutrition gets tricky since it is the CDI specialist’s job to make sure there is justification to support the diagnosis of malnutrition. I like to ask myself, would other providers come to the same conclusion based on the same information? If the answer is yes, then the diagnosis is supported by clinical indicators. I may not agree with the criteria the provider used--for  example, they may make the diagnosis based on pre-albumin levels--but it is not my role to evaluate the quality and/or accuracy of the diagnosis. Rather my role is to make sure it meets criteria for coding and reporting. Therefore, if the provider documents “mild malnutrition,” without being prompted by CDI/coding just because it doesn’t meet two of six ASPEN criteria, it does not mean that the diagnosis should not be reported/coded if supported by any clinical indicators.

Not all providers may be aware of and/or comfortable with using ASPEN criteria. I (and ACDIS) recommend that facilities develop their own definitions (paying deference to industry recommendations) for high risk diagnoses like malnutrition, sepsis and acute respiratory failure. When developing these definitions, do so in conjunction with coders, CDI specialists, medical staff representing the specialty, and dietitians. Do not leave establishing definitions to the discretion of CDI and/or coding. We are not diagnosticians.

Depending on the above situation you may or may not have a reportable diagnosis. If the diagnosis of malnutrition should be reported then it would be appropriate to always query for specificity, as the coding guidelines tell us diagnoses should be reported to the highest specificity, if known. This is where it is useful to have an organizational definition to help differentiate mild, moderate, and severe malnutrition. You are correct that any type of malnutrition, unspecified, mild or moderate will add a CC. Severe protein-calorie malnutrition will add a MCC. Many industry experts think that unspecified conditions will lose their designation as a CC after a year or two of reporting codes under ICD-10-CM in an effort to encourage the greater specificity allowed within the code set.

Emphasize the type of malnutrition as well as its severity with physicians. The most prevalent type of malnutrition in the United States is captured by the codes associated with “protein calorie” malnutrition. It is also unlikely for a patient to have severe or even moderate malnutrition unless the patient has not and does not receive healthcare services. Malnutrition is a condition that is usually prophylactically treated in healthcare through dietary supplements, meals, etc. Be sure the documentation clearly differentiates a person at risk for malnutrition from one who is suffering from malnutrition.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit This article originally published on the ACDIS Blog

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