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Reporting malnutrition

From the August ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Deborah Hale

Sidebar: Defining nutrition diagnoses

Documenting malnutrition as a secondary diagnosis helps establish the severity of an underlying illness, improves publicly reported data, and can increase reimbursement to the hospital. In general, secondary diagnoses are reportable if they affect patient care in terms of clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or nursing care and/or monitoring. In many cases, impaired nutritional status is considered significant enough to impact the severity of illness, the resulting length of stay and the cost of care in the acute care setting.

The coder must pay special attention to diagnoses considered to be complications and comorbidities (CCs), or major complications and comorbidities (MCCs). These increase the patient’s illness severity, and thus the MS-DRG payment to the hospital. An MCC reflects the highest level of severity for a secondary diagnosis, and results in increased use of hospital resources. MCCs for nutrition include severe malnutrition, protein malnutrition and emaciation. CCs result in increased hospital resource use as well, but to a lesser extent than MCCs. CC diagnoses include unspecified malnutrition, protein-energy undernutrition, cachexia, and body mass index less than 19 kg/m² (see sidebar for definitions of diagnoses).

Non-CCs, while reportable as secondary diagnoses, don’t increase the use of resources or impact MS-DRG reimbursement. They include mild or moderate malnutrition and failure to thrive.

Case Study

A patient was recently treated for pneumonia and is now admitted to the hospital with weakness and diarrhea that is found to be due to Clostridium difficile colitis. Laboratory results show a serum albumin level of 2.3 g/dL; nursing has recorded a BMI of 16 kg/m². A dietary evaluation finds that the patient is at 70% of normal body weight. Nutritional supplements and vitamins have been prescribed and given.

The following scenarios illustrate the impact of nutrition terminology on MS-DRG assignment, as shown by the reimbursement for this case. All scenarios are based on a hospital-specific rate of $5,500.

Scenario 1

• Principal diagnosis: C. diff. colitis.
• Secondary diagnosis: Failure to thrive.
• MS-DRG 373, major GI diagnosis without CC/MCC: $4,777.

Scenario 2

• Principal diagnosis: C. diff. colitis.
• Secondary diagnosis: Failure to thrive, and BMI less than 16 kg/m² as documented by dietitian or physician.
• MS-DRG 372, major GI diagnosis with CC: $7,191.

Scenario 3

• Principal diagnosis: C. diff. colitis.
• Secondary diagnosis: Failure to thrive, and severe malnutrition.
• MS-DRG 371, major GI diagnosis with MCC: $10,530.

Deborah Hale, a certified coding specialist, is president of Administrative Consultant Service, LLC, in Shawnee, Okla. E-mail us your coding questions.

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Defining nutrition diagnoses

Severe malnutrition. Values of patients who are severely malnourished include being less than 75% of normal weight, having a BMI of less than 16 kg/m², serum albumin level less than 2.4 g/dL, serum transferrin level less than 150 mg/dL, and total lymphocyte count less than 800 cells/mm^3.

Protein malnutrition. Undernutrition resulting from inadequate intake of protein.

Emaciation. Excessive leanness caused by disease or lack of nutrition, and characterized by an extreme loss of subcutaneous fat that results in an abnormally lean body.

Protein-energy undernutrition (PEU). Formerly called protein-energy malnutrition, PEU can be gradual, or sudden and total. Severity ranges from subclinical deficiencies to obvious wasting (with edema, hair loss and skin atrophy) to starvation. Multiple organ systems are often impaired, and diagnosis usually involves lab testing, including serum albumin.

PEU is common among the institutionalized elderly, and among patients with disorders that decrease appetite or impair nutrient digestion, absorption or metabolism. There is currently no ICD-9-CM code equivalent for “undernutrition,” so documentation of protein energy malnutrition is necessary until a more specific code is provided.

Unspecified malnutrition. Used in the absence of further descriptive terminology, such as the severity or type of malnutrition, in the physician’s documentation.

Cachexia. General weight loss and wasting, as occurs in the course of chronic disease or emotional disturbance.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated