6 Key Elements for Documenting Malnutrition
Dec 17, 2014
by Dr. Jon Elion

The proper documentation and associated coding and billing of malnutrition remains a challenge for clinicians and HIM professionals alike. The recently-published “ASPEN Guidelines” have helped provide a more standardized approach, but still need to be properly interpreted and applied. The guidelines recommend that the diagnosis of adult malnutrition be based on the presence of two or more of the following characteristics:

  • Insufficient energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation
  • Diminished functional status as measured by hand grip strength

Clinicians should have a systematic approach to documenting nutrition and malnutrition. The following six elements serve as an excellent template, and can guide the diagnosis as well as meet the needs of clinicians, reviewers, auditors and coders:

  • ELEMENT 1: History and Clinical Diagnosis: These can be helpful in raising suspicion for conditions that might be associated with the presence of inflammatory processes and nutritional disturbances.
  • ELEMENT 2: Clinical Signs and Physical Examination: The clinical indicators of inflammation include those associated with Systemic Inflammatory Response Syndrome (SIRS), including fever or hypothermia, tachycardia and tachypnea. The physical exam may reveal fluid accumulation, signs of weight gain or weight loss.
  • ELEMENT 3: Anthropometric Data: These include height, weight (especially being underweight), weight loss history, characteristics of skin folds, circumference, and other body composition metrics.
  • ELEMENT 4: Laboratory Indicators: Some indicators previously thought to be useful in the diagnosis of malnutrition (low albumin or pre-albumin) have not proven to be sensitive or specific and should be interpreted with restraint. These “hepatic proteins” may not accurately measure nutritional repletion or malnutrition, but it turns out that they are useful indicators of morbidity and mortality. Markers of inflammation may be present, such as elevated C-reactive protein, elevated or low white count, and elevated glucose. More complex markers include negative nitrogen balance and elevated metabolic rates.
  • ELEMENT 5: Dietary Data: A modified diet history or 24-hour dietary recall can be a useful tool. This typically involves the use of a form that is filled out by the patient, then analyzed by a computer-based nutritional assessment program. This can be misleading if used as the only assessment, as a single sample may not be representative of the patient’s typical intake.
  • ELEMENT 6: Functional Outcomes: These include an assessment of strength and physical performance, along with other associated findings.

Evaluation of nutritional status during a hospitalization and especially after surgery is extremely important. Malnutrition can develop due to anorexia, intentional withholding of oral feedings (when needed for tests, anesthesia, etc.), inadequate attempts at oral feeding, or prolonged support on a ventilator. It is important to remember that providing nutritional support during hospitalization does not in and of itself imply that a malnutrition state is being treated, and coding for malnutrition should be approached with caution and skepticism in these circumstances.

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