July 06, 2009 | | Comments 4
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Feeding the brain on malnutrition documentation

Remember the old 80’s ad for the Big Mac? “Two all beef patties, special sauce, lettuce, cheese,

Documenting malnutrition might be easier than building a Big Mac.

Documenting malnutrition might be easier than building a Big Mac.

pickles, cheese, onions on a sesame seed bun.”

These lyrics and the associated fast food mania was a sign of what I will call food affluence, when we valued time over money, convenience over quality and taste over nutrition. And yet during that same period, the prevalence of malnutrition in hospitalized patients was investigated numerous times with results indicating the malnutrition was a major concern for elderly, hospitalized patients. The effects of malnutrition and the associated costs were also vastly studied in late 80’s and early 90’s. So why has this issue not resolved?

Of course, the issue is once again poor documentation of the severity of the diagnosis and decision making regarding care of this condition. Unfortunately, the malnutrition codes differ from the usual medical terminology. The severity of the malnutrition is indicated in the codes and while clinical severity is typically indicated in risk not actual diagnosis.

Most nutritional consult forms provide a method for the dietitian to indicate risk for malnutrition, not an actual diagnostic statement. Many forms actually ask the dietitian to specify the level of risk of malnutrition by checking the appropriate box for low, medium/moderate, or high. These indicators do not easily translate into an ICD-9-CM code forcing professional coders and CDI specialists to search for other indicators of the severity of malnutrition to clarify diagnoses with the physician.

In an attempt clarify the need to document the severity of malnutrition in adult hospitalized patients, Coding Clinic addressed the issue in the fourth quarter of 1992. It says:

“Malnutrition is generally thought of as a problem associated with children. Increasingly, it is becoming a problem for the elderly of this country who are unable to properly care for themselves, and who do not have the resources to obtain daily care…In order to improve the reporting of malnutrition among the elderly, it is important for physicians to document the condition in the medical record and for coders to be aware of malnutrition as a potential diagnosis.” Coding Clinic, October 1, 1992 Page: 24 to 25

Malnutrition ICD-9 codes are highly specific and exact documentation is necessary for appropriateness of code assignment. The documentation specialist’s challenge is to assist the healthcare provider by identifying the clinical indicators that may indicate the degree of malnutrition. Another strategy is to include the dietitian in the discussion of the clinical picture of the patient and allow them to guide the documentation through a complete assessment and indication of risk for the patient. Although appropriate documentation of severity of illness is a CDI specialist’s target, ultimately prevention of complications and provision of quality patient care is the goal. Through collaboration with the healthcare team we can serve as a resource to aid in better identification of the level of malnutrition.

Included below are clinical indicators for malnutrition as well as the appropriate ICD-9 codes.  So serve up a little “brain food” and less “fast food” and be a healthy alternative resource for healthcare providers as they care and treat patients with nutritional concerns!

Risk factors for malnutrition include:

  • Chronic disease
  • Inadequate intake
  • Fever
  • Infection
  • Trauma
  • Malabsorption
  • Malignancy
  • Chronic renal failure

Clinical indicators for malnutrition include:

  • Loss of subq fat, muscle wasting of the extremities, (anthropometric measurements)
  • Skin lesions, decubitus ulcers, hair loss, poor wound healing
  • Lethargy
  • Constipation
  • Decreased pulse/respiratory rates, relative hypotension
  • Hepatomegaly d/t fat infiltration
  • Unintentional weight loss of 10 pounds or more over a period of 6 months

Lab data indicators for malnutrition include:

  • Serum albumin < 2.1
    • For assessment of severe malnutrition
  • Serum pre-albumin < 5
    • For assessment of response to nutritional support
  • Serum Total Protein < 5
  • Serum transferrin < 1
  • Abnormally low VLDL/LDL levels
  • TIBC <200
  • Lymphocytes < 1500
    • < 800 Severe malnutrition
  • Serum Cholesterol < 160

Treatment for malnutrition:

  • Dietary consultation
  • Intake & Output monitoring
  • Protein-calorie dietary supplementation
  • Calorie Counts
  • Daily weights
  • PEG tube
  • Psychiatric consultation
  • Appetite stimulants (Megace)

Malnutrition codes include:

  • 260 Protein Malnutrition MC
  • 261 Severe Malnutrition MCC
  • 262 Severe Protein/Calorie Malnutrition NEC MCC
  • 263.1 Mild Malnutrition
  • 263.0 Moderate Malnutrition CC
  • 263.9 Malnutrition, calorie CC
  • 263.8 Malnutrition, specified NEC CC

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Filed Under: CodingPhysician queries

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Fran Jurcak About the Author: Fran Jurcak, RN, MSN, CCDS is a manager with Wellspring Partners, a division of Huron Consulting, and has been a nurse for 25 years. She has a strong clinical and educational background having served as a professor of nursing for many years. She is currently active in several professional associations directed at revenue cycle and documentation management.

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  1. When I first started I became very frustrated as the physicians did not seem to recognize malnutrition. As mentioned above the dieticians are a huge help. I spent some time with them and explained why it was important to capture this diagnosis. Their frustration was palpable. They complained little time or recognition was given to them from the medical staff for their consults. We turned it into a win-win for each of us. I asked them to start documenting malnutrition according to severity and type (they would write interms of at risk for, possibles etc) and I would begin to query off their documentation. I have a concurrent response rate of high 80’s in percent. So soon we were seeing acknowledgent in the physician’s notes concerning malnutrition as well as orders to compliment the proposed plans by the dieticians. They felt listened to and were so thankful to me. I am so thankful to them!

  2. We have moved our CDI program into the pediatric population.
    Can anyone help me with indicators for malnutrition other than growth charts?

  3. The American Dietetic Assn and ASPEN are forming a group to work on this topic for pediatrics. New markers have been published on the ADA website in the Nutrition Care Manual from collaborative work with a number of organizations.

  4. The Academy of Nutrition and Dietetics (AND; formerly American Dietetic Associaiton) and A.S.P.E.N. have completed and approved clinical characteristics for malnutrition. These characteristics are published in AND’s Online Nutrition Care Manual and on AND’s website. There are six categories of information that Registered Dietitians (RDs)and other clinicians may document relative to the presence of severe or non-severe (moderate) malnutrition. Serum proteins and other laboratory data are not included because they are non-specific for malnutrition. A paper with additional information will be published in the AND and A.S.P.E.N. journals in 2012.

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