Note from the Instructor: Unveiling the enigma of malnutrition through the lens of denial prevention

by Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS

In the intricate landscape of healthcare documentation, malnutrition stands out as a nuanced yet pervasive issue that warrants attention from CDI teams. Beyond its clinical implications, malnutrition documentation does hold “weight” (no pun intended) in denial prevention efforts, making it imperative for CDI professionals to grasp its intricacies. To help, we can explore the multifaceted nature of malnutrition, its impact on denial prevention, assessment strategies, and the pivotal role CDI teams play in addressing this crucial aspect of healthcare documentation.

Understanding malnutrition: Beyond the surface

Malnutrition transcends mere dietary inadequacy; it encompasses a spectrum of nutritional deficiencies stemming from factors such as inadequate intake, absorption, or utilization of nutrients. Contrary to popular belief, malnutrition is not limited to undernourishment; it also encompasses overnutrition, micronutrient deficiencies, and imbalances in nutrient intake.

Malnutrition pervades healthcare settings, affecting patients across age groups and clinical conditions. Its repercussions extend beyond clinical outcomes to impact denial rates, reimbursement, and healthcare costs. Inaccurate or incomplete documentation of malnutrition can lead to denials, delayed reimbursement, and increased administrative burden, underscoring the importance of meticulous documentation practices.

Assessment strategies: Unraveling the malnutrition conundrum

Accurate assessment serves as the cornerstone of effective malnutrition management and denial prevention. CDI teams must familiarize themselves with various assessment tools and methodologies to identify malnourished patients accurately.

• Subjective global assessment (SGA): Leveraging clinical judgment, medical history, and physical examination to categorize patients based on their nutritional status.
• Nutritional risk screening (NRS-2002): Evaluating nutritional risk utilizing parameters such as body mass index (BMI), weight loss, and disease severity.
• Malnutrition screening tool (MST): Employing a rapid screening tool to identify patients at risk of malnutrition based on recent weight loss and appetite changes.
• Anthropometric measurements: Utilizing assessments of weight, height, BMI, and body composition to gauge nutritional status.
• Laboratory parameters: Incorporating biomarkers such as serum albumin, pre-albumin, and lymphocyte counts to assess nutritional status and inflammation.
• A.S.P.E.N.’s Nutritional Care Pathway (nutritioncare.org): A pathway from admission to discharge for providers and clinical teams to utilize for screening, assessment, and care planning.
• Global Malnutrition Composite Score (GMCS): An electronic clinical quality measure encompassing four key components aimed at identifying and addressing malnutrition among inpatients. Approved by the Center for Medicare and Medicaid Services (CMS) for inclusion in the Hospital Inpatient Quality Reporting (IQR) Program, it will become effective in 2024. Supporting tools and resources are available to facilitate the implementation of this measure and can be accessed here.

Malnutrition: A clinical example

Meet Mrs. Smith, a 75-year-old retired teacher admitted to the hospital with exacerbation of chronic obstructive pulmonary disease (COPD).

Mrs. Smith's journey through the healthcare system illuminates the critical role of accurate malnutrition documentation in denial prevention, particularly when incorporating criteria outlined by The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) in their consensus statement published in the ASPEN Journal in 2012, and the Global Leadership Initiative on Malnutrition’s (GLIM) consensus report published in the ASPEN Journal in 2019, on the criteria for the diagnosis of malnutrition.

Upon admission, Mrs. Smith presents with symptoms of COPD exacerbation, including dyspnea and increased sputum production. However, a deeper dive into her medical history reveals significant malnutrition risk factors. Over the past six months, Mrs. Smith has experienced unintended weight loss of 10% of her body weight and reports a decline in appetite, often skipping meals due to fatigue and dyspnea. These findings align with criteria for diagnosing malnutrition, which emphasize weight loss, inadequate nutrient intake, and altered body composition as key indicators.

Recognizing the importance of comprehensive malnutrition assessment, the CDI team collaborates with Mrs. Smith's treating physician to conduct a thorough evaluation using the GLIM criteria. According to GLIM, Mrs. Smith meets the criteria for malnutrition diagnosis, as evidenced by her weight loss, reduced food intake, and altered body composition.

With this insight, the CDI specialist queries the physician for clarity of documentation of Mrs. Smith's nutrition status according to the established criteria. Detailed documentation by the provider includes the BMI, percentage of weight loss, changes in dietary habits, and physical manifestations of malnutrition, including muscle wasting and diminished subcutaneous fat stores. The provider also collaborates with the registered dietician to assess grip strength and provide a nutritional assessment with recommendations.

Furthermore, the CDI team provides education to the healthcare providers involved in Mrs. Smith's care, emphasizing the significance of accurate nutrition documentation. By aligning documentation with ASPEN/ADN and GLIM criteria, the CDI team ensures that Mrs. Smith's medical record reflects the accuracy of her condition and care needs and supports precise coding and billing, reducing the risk of denials associated with insufficient documentation.

As Mrs. Smith progresses through her hospitalization, interdisciplinary collaboration and adherence to evidence-based criteria continue to guide her care. She receives nutritional supplementation. Care management efforts address her home care needs and follow-up appointments. By incorporating ASPEN/ADN and GLIM criteria into Mrs. Smith's documentation, the CDI team not only facilitates accurate reimbursement but also enhances the quality of care and improves patient outcomes.

The CDI role in denial prevention

CDI teams are pivotal in mitigating denial risks associated with malnutrition documentation through proactive measures such as:

• Accurate documentation: Ensuring meticulous documentation of malnutrition severity, etiology, and clinical implications to support coding accuracy and mitigate denial risks.
• Clinical validation: Collaborating with healthcare providers to ensure documentation aligns with the patient's clinical presentation, severity of malnutrition, and coding guidelines to reduce denial risks associated with discrepancies.
• Education and training: Providing targeted education to healthcare providers on malnutrition assessment, documentation requirements, and coding guidelines to enhance documentation accuracy and mitigate denial risks.
• Querying for clarity: Proactively querying healthcare providers to clarify ambiguous or incomplete documentation related to malnutrition, which mitigates denial risks associated with insufficient documentation.
• Interdisciplinary collaboration: Engaging in interdisciplinary collaboration with nutritionists, dietitians, and other healthcare professionals to develop comprehensive care plans and documentation strategies that mitigate denial risks associated with malnutrition.

Navigating denial prevention challenges

Despite its significance, malnutrition documentation often faces challenges such as underreporting, lack of specificity, and inconsistencies. CDI teams can address these challenges through methods such as:

• Comprehensive documentation reviews: Conducting thorough reviews of medical records to identify documentation gaps and opportunities for improvement, mitigating denial risks associated with incomplete or inaccurate documentation.
• Real-time feedback and education: Offering real-time feedback and education to healthcare providers on malnutrition documentation best practices, coding guidelines, and denial prevention strategies to enhance documentation accuracy and mitigate denial risks.
• Utilization of technology: Leveraging technology solutions such as electronic health records and clinical decision support systems to streamline documentation processes, facilitate real-time feedback, and promote adherence to malnutrition assessment and coding guidelines, reducing denial risks associated with documentation errors.

Malnutrition documentation plays a critical role in denial prevention efforts, influencing reimbursement, healthcare costs, and administrative efficiency. CDI teams serve as guardians of documentation accuracy, ensuring that malnutrition is documented comprehensively and accurately to mitigate denial risks and support optimal patient care. By leveraging their expertise, fostering interdisciplinary collaboration, and advocating for best practices in malnutrition documentation, CDI professionals can safeguard against denials, enhance reimbursement accuracy, and ultimately improve patient outcomes.

Editor’s note: Wilk is a CDI education specialist for HCPro and ACDIS. Contact her at deanne.wilk@hcpro.com. For reference, please also see this CDI Journal article on nutrition assessment documentation.