Q&A: Severe versus moderate protein-calorie malnutrition

Q: The provider initially documents severe protein-calorie malnutrition. During the concurrent review, the CDI reviewer issues a query for validation because the patient does not meet the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria or Global Leadership Initiative on Malnutrition (GLIM) criteria for severe malnutrition. In response, the physician documents moderate protein-calorie malnutrition. However, at discharge, the diagnosis of severe protein-calorie malnutrition is carried forward into the discharge summary, creating conflicting documentation regarding the severity of the condition.

Is it appropriate to send query to clarify a diagnosis that has already been addressed through a concurrent query during the inpatient stay? How should coding proceed when the query response conflicts with the discharge summary?

A: These questions can be answered using the basis from the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice – 2026 Update.

First, see this quote from p. 20, section IX:

A subsequent query may be appropriate when additional clarification is needed based on new or evolving clinical information, or when a prior response requires further specificity to accurately reflect the patient’s condition. Multiple queries may also be necessary when different elements of a diagnosis must be clarified to support accurate code assignment, such as acuity, specificity, or associated conditions. For example, separate clarification may be needed to establish both the presence and the type of a condition, such as heart failure.

Additionally, p. 18, section VII, says, “When conflicting documentation is present, the attending provider (as defined by organizational policy) should be queried to resolve any discrepancies.”

In this scenario, the provider documents severe protein-calorie malnutrition. The process is:

Query sent à Response = Moderate protein-calorie malnutrition

The next steps depend on the provider's response to the query, how that response was documented, and your organization's policies.

Scenario 1: Documentation Changed

• The provider updated the medical record to document moderate protein-calorie malnutrition in response to the query.
• However, the discharge summary later documented severe protein-calorie malnutrition.

This creates conflicting documentation. A new query should be sent to the discharging provider to clarify the discrepancy between the discharge summary, prior documentation, and the query response.

Scenario 2: Documentation Not Changed

• The provider responded to the query but continued to document severe protein-calorie malnutrition in the medical record.
• Your organization and EHR consider the query response part of the legal health record.

In this case, moderate protein-calorie malnutrition would be coded as the final diagnosis.

A new query may be needed depending on how the provider responded to the original query. Then, depending on IF the documentation was updated in the medical record, and whether your organization's policies allow query responses to be considered part of the legal health/medical record. 

Review both the provider's documentation and your organization's query policy before determining if an additional query is necessary or the existing query response can be used for code assignment.

Editor’s note: Lynette Byerly BSN, RN, CCDS, CCS, a CDI education specialist at ACDIS/HCPro, answered this question. Contact her at lynette.byerly@hcpro.com.