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July 2014

Documenting Malnutrition
By Jonathan Elion, MD, FACC
For The Record
Vol. 26 No. 7 P. 26

There have been several well-publicized instances where hospitals have gotten into trouble for their coding and billing practices related to various malnutrition diagnoses. A common thread through all of these occurrences was the lack of a clinical assessment that suggested malnutrition in the first place. The diagnosis never should be considered solely on the basis of a laboratory abnormality; the clinical guidelines should be applied to patients who have some clinical indication that malnutrition may be present.

The proper documentation and associated coding and billing of malnutrition remain a challenge for clinicians and HIM professionals alike. Recently published guidelines have helped provide a more standardized approach but still must be properly interpreted and applied. The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend that the diagnosis of adult malnutrition be based on the presence of two or more of the following characteristics1:

• insufficient energy intake;

• weight loss;

• loss of muscle mass;

• loss of subcutaneous fat;

• localized or generalized fluid accumulation; and

• diminished functional status as measured by hand grip strength.

While the ASPEN guidelines have been widely publicized, an equally important companion tutorial developed by Penn State University’s department of nutritional sciences provides a useful systematic approach to assessing nutrition and malnutrition.2 The tool provides an outline that can serve as an excellent template for clinical documentation. This framework can guide the diagnosis plus meet the needs of clinicians, reviewers, auditors, and coders.

The tutorial recommends the following be included in any clinical documentation:

History and clinical diagnosis: These can be helpful in raising suspicion for conditions that may be associated with the presence of inflammatory processes and nutritional disturbances.

Clinical signs and physical examination: The clinical indicators of inflammation include those associated with systemic inflammatory response syndrome, including fever or hypothermia, tachycardia, and tachypnea. The physical exam may reveal fluid accumulation and signs of weight gain or loss.

Anthropometric data: This information includes height, weight (especially being underweight), weight-loss history, characteristics of skin folds, circumference, and other body composition metrics.

Laboratory indicators: Some indicators (eg, low albumin or prealbumin) previously thought to be useful in a malnutrition diagnosis have not proven to be sensitive or specific and should be interpreted with restraint. While these hepatic proteins may not accurately measure nutritional repletion or malnutrition, they are useful indicators of morbidity and mortality. Inflammation markers, such as elevated C-reactive protein, elevated or low white blood cell count, and elevated glucose, may be present. More complex markers include negative nitrogen balance and elevated metabolic rates.

Dietary data: A modified diet history or a 24-hour dietary recall can be a useful tool. Typically, a patient completes a form, which then is analyzed by a computer-based nutritional assessment program. However, because a single sample may not be representative of the patient’s typical intake, the results can be misleading. Therefore, it is best not to use the data as the sole assessment.

Functional outcomes: This involves an assessment of strength and physical performance along with other associated findings.

Watch for Warning Signs
Providers must be aware that nutritional status may be an indicator of a more serious condition. The following conditions are known to have a high prevalence of associated malnutrition (rate of malnutrition in parentheses)3:

• pancreatic cancer (85%);

• lung cancer (13% to 50%);

• head and neck cancer (24% to 88%);

• gastrointestinal cancer (55% to 80%);

• cerebrovascular accident (stroke) (16% to 49%); and

• COPD (25%).

An evaluation of nutritional status during hospitalization, especially postsurgery, is essential to patient care. Malnutrition can develop due to anorexia, iatrogenic starvation (when necessary for tests, anesthesia, etc), inadequate attempts at oral feeding, and prolonged ventilator support. It is important to remember that providing nutritional support during hospitalization does not necessarily mean that a form of malnutrition is being treated. As a result, coding for malnutrition must be approached with caution and skepticism.

Because there are only a few codes associated with malnutrition, next October’s scheduled conversion to ICD-10 should not be too cumbersome for coders faced with chronicling the condition. The chart below provides a general crossover between ICD-9 and ICD-10.






Unspecified severe protein-calorie malnutrition



Moderate protein-calorie malnutrition



Mild protein-calorie malnutrition



Unspecified protein-calorie malnutrition



Applicable to malnutrition, not otherwise specified (NOS)
Protein-calorie imbalance NOS



Morbid (severe) obesity due to excess calories



Use additional code to identify BMI, if known (Z68.-). Type 1 excludes abnormal weight loss (R63.4), anorexia nervosa (F50.0-), and malnutrition (E40-E46).



Abnormal weight loss



Applicable to wasting syndrome. Code first underlying condition, if known. Type 1 excludes abnormal weight loss (R63.4) and nutritional marasmus (E41).



BMI 19 or less, adult



Maramic kwashiorkor



Marasmic kwashiorkor
Unspecified severe protein calorie malnutrition


Practical Tips
A collaborative approach to the evaluation and management of nutrition and malnutrition works best. At minimum, it should include physicians, nurses, and registered dietitians. Some hospitals require a dietary consultation on the chart before any malnutrition diagnoses can be coded.

To reduce the odds of malnutrition being improperly documented, adopt a practical strategy that includes the following:

• Before proceeding to apply any guidelines for a malnutrition assessment, be sure there is a clinical sense of a potential nutritional disturbance.

• To further confirm the diagnosis, verify that at least two of the six characteristics from the ASPEN guidelines are present.

• Avoid the temptation to query the physician about malnutrition or code it when the only evidence is an abnormal lab result.

• Use the six-point template suggested by the ASPEN guidelines and the adult nutrition assessment tutorial to provide complete documentation.

• Look for the possible presence of other conditions and diagnoses that may produce or be associated with malnutrition.

• Do not confuse the need for nutrition for the presence of malnutrition.

— Jonathan Elion, MD, FACC, is founder of ChartWise Medical Systems.

1. White JV, Guenter P, Jensen G, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.

2. Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. J Parenter Enteral Nutr. 2012;36(3):267-274.

3. National Alliance for Infusion Therapy and the American Society for Parenteral and Enteral Nutrition Public Policy Committee and Board of Directors. Disease-related malnutrition and enteral nutrition therapy: a significant problem with a cost-effective solution. Nutr Clin Pract. 2010;25(5):548-554.