Guest column: Nutrition and COVID-19
by Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA
Recent audit activity and the Office of Inspector General’s continued scrutiny toward malnutrition diagnoses, let’s spend a little time digging into the coding and documentation requirements for this tricky diagnosis, particularly in the case of COVID-19 patients.
Malnutrition has traditionally been defined as a chronic state of nutritional deprivation resulting in a constellation of characteristic clinical findings. It is based on severity. While the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria are effective for diagnosing malnutrition, they are less useful for defining severe malnutrition. The Global Leadership Initiative on Malnutrition (GLIM) criteria are less subjective and more clinically intuitive, and they include parameters that are more consistent with the traditional concepts of non-severe and severe malnutrition.
When provider documentation indicates that a patient’s malnutrition has progressed in severity during the hospital stay, coding professionals are instructed to assign one code to capture the highest level of severity. Additionally, they should assign the present on admission (POA) indicator that indicates the POA status of the initial malnutrition severity. For example, if moderate malnutrition is POA and progresses to severe, report severe malnutrition with the POA indicator of “Yes.” CDI professionals should query the provider if it is unclear whether the malnutrition has progressed to a more severe state or whether the record contains conflicting documentation of the patient’s malnutrition severity.
Regardless of the POA status, CDI professionals should ensure physician documentation/clinical evidence clearly supports a complete clinical picture of malnutrition. It may be necessary to submit a clinical validation query if this is not the case. Provider documentation and queries should be supported by underlying conditions/acute illnesses that place the patient at risk for, or contribute to, malnutrition. Conditions that can lead to malnutrition include:
- Crohn's disease
- Short bowel syndrome
- Malabsorption syndrome
- Cystic fibrosis
- Eating disorders
- End-stage disorders such as chronic obstructive pulmonary disease (COPD), respiratory failure, congestive heart failure, end-stage renal disease (ESRD), hepatic disease, HIV, severe burns and injuries, systemic infections, and cancer
In situations when the severity of malnutrition is documented by a registered dietitian but not by the attending provider, the CDI professional should query as well. There are no guidelines that permit the use of a registered dietitian’s documentation of the degree or severity of malnutrition for code assignment. The severity of malnutrition is part of the diagnosis of malnutrition, which can only be made by the attending provider. If the provider reviews and signs off on the dietitian’s documentation, the facility may develop a policy to address whether the malnutrition severity and diagnosis can be coded.
Recent evidence examining adults infected with COVID-19 has indicated that malnutrition has a significant impact on health outcomes. Individuals who have multiple comorbidities, are older adults, or are malnourished are at increased risk of being admitted to the ICU and dying from a COVID-19 infection.
The Centers for Disease Control reports that 94% of people hospitalized for COVID-19 have one or more underlying medical conditions, including obesity, Type 2 diabetes, and heart disease. CDI professionals need to review records carefully for documentation and clinical indicators for all comorbid conditions, such as asthma, COPD, cystic fibrosis, diabetes, ESRD, HIV, hypertension, malnutrition, liver diseases, and pulmonary fibrosis. It is important to capture these comorbidities for accurate reporting of epidemiological risk factors. For adults with suspected or confirmed COVID-19 infections, the Malnutrition Screening Tool can be used to identify individuals who are at risk of malnutrition, regardless of their inpatient or outpatient status.
Editor’s note: Kuqi is a member of the ACDIS CDI Leadership Council, PHIMA, and the American Urological Association, and a volunteer for the AHIMA Foundation Research Network. Contact her at firstname.lastname@example.org. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.