Guest post: Advice for coding and documentation malnutrition
by Christine Donnamiller, RN, ACDIS-Approved CDI Apprentice
Recently, we have seen a rise in the documented diagnosis of malnutrition at our inpatient facilities. Malnutrition is highly reviewed among auditors and just as commonly denied among payers. I want to share the most recent coding updates and best practice guidelines with you.
On August 17, 2020, a joint statement was released regarding malnutrition by a task force made up of several renowned organizations including American Society for Parenteral and Enteral Nutrition (ASPEN), ACDIS, Academy of Nutrition and Dietetics, and the American Society for Nutrition (ASN). The task force has united due to the lack of transparency around malnutrition criteria used by CMS and Office of Inspector General (OIG) auditors in reviewing claims for inpatient hospital billing.
Despite the task force’s ongoing efforts to understand best practices for diagnosing, documenting, and coding malnutrition, CMS and the OIG have been unable to provide any criteria confirmations. The task force continues to collaborate with CMS, the OIG, and the United States Department of Health and Human Services to deal with this issue. The task force states both the Global Leadership Initiative on Malnutrition (GLIM) and ASPEN criteria represent consensus-based frameworks.
ACDIS states many organizations have adopted ASPEN criteria, GLIM criteria, or a combination as a standard approach. Furthermore, not included are Albumin nor PAB as defining characteristics of malnutrition, based on evidence that serum levels of these proteins do not change in response to changes in nutrient intake. Although labs, CRP, Albumin, and PAB are supportive proxy measure of inflammation, they are not diagnostic criteria. Find more information here.
Despite the confusion between the various diagnostic criteria auditors use and that which organizations employ, there are a couple pieces of advice we can share with you.
First, malnutrition is not integral to chronic disease from a coding perspective, according to the Official Guidelines for Coding and Reporting and the American Hospital Association’s Coding Clinics. Guidance in these publications direct coders to code malnutrition separately from chronic disease such as cancer, malignant disease, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, rheumatoid arthritis, any disease with chronic or recurrent inflammation.
Secondly, coders are instructed to code a present on admission (POA) indicator of “yes” when the severity of malnutrition progresses or worsens during the admission, resulting in a higher severity rating.
This article was written as a letter to the AVITA physicians with the intent of sharing the most updated clinically accepted criteria for the diagnosis of malnutrition. We are seeing less documentation of malnutrition that’s not clinically supported and we’re issuing nearly zero clinical validation queries since this education.
Editor’s note: Donnamiller is a CDI specialist at AVITA Health System based on Ohio. Contact her at cdonnamiller@avitahs.org. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.