Q&A: Reporting malnutrition based on dietitian documentation

Q: I’ve heard that the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria cannot be applied to diagnose malnutrition based solely on the dietitian’s documentation. Can you please elaborate on why this is the case?

A: This is a great question.

Section I.B.14 of the Official Guidelines for Coding and Reporting states:

Code assignment is based on the documentation by the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record. These exceptions include codes for:

• Body Mass Index (BMI)

• Depth of non-pressure chronic ulcers

• Pressure ulcer stage

• Coma scale

• NIH stroke scale (NIHSS)

• Social determinants of health (SDOH)

• Laterality

• Blood alcohol level

This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. The BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses.

A registered dietician does not fall under this guideline. Registered dieticians are experts and do perform a nutrition-focused physical exam (NFPE) which is an element of ASPEN criteria. This exam and documentation of findings helps clinically support a malnutrition diagnosis. Only the patient’s provider or other qualified healthcare practitioners (i.e., residents, physician assistants, or nurse practitioners) can diagnose the patient. Typically, registered dieticians document their findings and recommendations based on their interview and assessment of the patient. The provider is responsible for making the diagnosis and ordering treatment.

It is not recommended that the physician just date and sign the dietary note as a method of documenting the diagnosis; they should also give some indication that they agree with the dietary note, including the diagnosis and treatment. Malnutrition is a heavily audited diagnosis, often leading to denials. So, it’s always best to make sure that anyone documenting in the medical record supports the diagnosis and demonstrates what is being done for the patient related to this diagnosis, such as the use of a special bed type and/or scale or required assistance with transferring.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.