Q&A: Documenting and coding severe malnutrition

Q: What clinical information can be used to support the reported diagnosis of severe malnutrition and how would this be coded in ICD-10-CM?

A: There are a number of criteria used to diagnose and identify the severity of malnutrition. The two main criteria are the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Global Leadership Initiative on Malnutrition (GLIM). When performing a clinical validation review, start by confirming the presence of malnutrition and then apply validation to the level of severity.

Capturing severity allows you to also capture the increased patient complexity. The diagnosis of malnutrition affects most risk adjustment methodologies. Malnutrition (reported to the E44 code group) provides a CC when documented as mild, moderate, and unspecified. Severe malnutrition provides (E43) an MCC as a secondary diagnosis.

With any diagnosis, determine any contributing etiologies or what has led to the malnourished state. The ASPEN criteria speaks to a continuum of inadequate nutritional intake as well as increased requirements, impaired absorption, altered transport, and altered nutrient use as contributing factors to malnutrition. The GLIM criteria speaks to these same contributing factors but also identifies disease associated inflammatory mechanisms, especially those related to chronic disease as a factor.

ASPEN criteria identify three situations in which malnutrition can occur:

1. Acute illness/injury present for less than three months. Examples include multi-trauma, surgery, prolonged intubation, or hospitalization.
2. Chronic illness present for three months or longer. Examples include metastatic disease, chronic lung disease, or HIV disease.
3. Social and environmental circumstances limiting access or ability to self-care.

In 2020, the Office of the Inspector General (OIG) identified over-reporting of severe malnutrition as an area of concern. One key factor missing in their investigation was the lack of treatment applied to correct the malnutrition, especially a severe level of malnutrition. This report from the OIG clearly outlined that treatment protocols must match the severity of malnutrition reported, meaning an individual identified as severely malnourished would require not only significant nutritional support during a hospital encounter, but also attention to the contributing factors and care beyond that acute care encounter. This level of care is considered a clinical indicator to support the presence of malnutrition, or the reported level of severity.

Documentation stating severe protein calorie malnutrition as supported by ASPEN or GLIM diagnostic criteria should also be supported by an appropriate treatment plan addressing the underlying etiology and follow through beyond the acute care setting. For example, documentation might read:

Mr. Smith demonstrates a severe protein calorie malnutrition, as evidenced by an estimated protein calorie intake less than 70% of energy requirements in the presence of chronic lung disease. Unintentional weight loss of over 20% bodyweight in the last 12 months, with a severe loss of muscle mass and body fat noted. BMI of 18. Nutritional consult has initiated a calorie count. High calorie protein shakes and a meal plan has been adjusted to allow for six small meals versus traditional schedule due to the patient’s frailty and high levels of fatigue. Upon discharge the patient will be followed by home health to include assist with meal prep, nutritional follow-up, and support of other activities of daily living.

The treatment and follow up care are clinical indicators supporting the presence of severe malnutrition, requiring further care and intervention. The OIG concluded that a severe level of malnutrition required treatment and follow-up care and should be addressed in the treatment plan. This information should be reflected consistently throughout the provider documentation, as well as nursing and dietician documentation.

ASPEN defines moderate/severe malnutrition in the three contexts of acute illness/injury, chronic illness, and social circumstances. The patient’s specific situation and contributing factors need to be documented to apply these criteria correctly. The ASPEN criterion for the severe level are:

Severe malnutrition in an acute care setting:

• Energy intake: less than (<) 50% estimates energy requirement for greater than (>) 5 days
• Weight loss (% of body weight):
  • >2% in one week; or
  • >5% in one month; or 
  • >7.5% in three months
• Muscle mass loss: moderate
• Body fat loss: moderate
• Edema masking weight loss: moderate to severe
• Reduced grip strength: measurably reduced

Severe malnutrition in the setting of chronic disease:

• Energy intake: less than (<) 75% estimates energy requirement for greater than (>) 1 month
• Weight loss (% of body weight):
  • >5% in one month; or
  • >7.5% in three months; or 
  • >10% in six months
  • >20% in a year
• Muscle mass loss: severe
• Body fat loss: severe
• Edema masking weight loss: severe
• Reduced grip strength: measurably reduced

Severe malnutrition secondary to social circumstances:

• Energy intake: less than (<) 50% estimates energy requirement for greater than (>) 1 month
• Weight loss (% of body weight):
  • >5% in one month; or
  • >7.5% in three months; or 
  • >10% in six months
  • >20% in a year
• Muscle mass loss: severe
• Body fat loss: severe
• Edema masking weight loss: severe
• Reduced grip strength: measurably reduced

In 2018, ASPEN joined with  the European Society for Clinical Nutrition and Metabolism, the Latin American Nutritional Federation, and the Parenteral and Enteral Nutrition Society of Asia to publish Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community in the Journal of Parenteral and Enteral Nutrition.

The GLIM criteria consist of five elements: two etiologic and three based on clinical findings (phenotypic). The diagnosis of malnutrition is based on the presence of at least one etiologic and one phenotypic criterion. Etiologic criteria are used to guide intervention and measured outcomes. 

Etiologic Criteria

Phenotypic Criteria

The phenotypic criteria assist in grading severity. The GLIM criteria for the severe level are listed below. One criterion from these listed must be met.

The record should consistently support the presence of malnutrition, the level of severity as demonstrated by assessment and actions to treat the malnutrition both in the immediate acute care environment and in follow up post discharge.

Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, CDI education director at HCPro, answered this question. For information regarding CDI Boot Camps, click here.