589372

research-article2015

NCPXXX10.1177/0884533615589372Nutrition in Clinical PracticePhillips

Invited Review

Accurate Documentation of Malnutrition Diagnosis Reflects

Increased Healthcare Resource Utilization

Nutrition in Clinical Practice

Volume XX Number X
Month 201X 15
2015 American Society
for Parenteral and Enteral Nutrition
DOI: 10.1177/0884533615589372
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Wendy Phillips, MS, RD, CNSC, CLE1

Abstract
Nutrition support professionals often care for the sickest of hospitalized patients. An understanding of healthcare payment models can
help the nutrition support professional know how documentation of nutrition status can ensure maximum resources are available to care
for these patients. Medicare is the major funding source for many hospitals in the United States. Hospitals receive payments using the
Acute Care Hospital Inpatient Prospective Payment System, which classifies patients into Medical Severity Diagnosis-Related Groups
(MS-DRGs) to determine payment amounts. Documentation of comorbidities and complications can increase the payment hospitals
receive to offset increased resource utilization. This article explains how malnutrition documentation and coding can influence the case
mix index, an indicator of level of acuity of patients treated at the hospital, and the payment the hospital receives to care for the patient.
(Nutr Clin Pract.XXXX;xx:xx-xx)

Keywords
fee-for-service plans; insurance; Medicare; Diagnosis-Related Groups; prospective payment system; nutrition assessment; nutrition
therapy

Nutrition support professionals often care for the sickest of

hospitalized patients. These patients are the ones who have lost
the ability to eat and/or drink in a physiologically normal way
and many times have also lost the ability to digest, absorb, and
assimilate nutrients properly. An understanding of healthcare
payment models can help the nutrition support professional
know how documentation of nutrition status can ensure maximum resources are available to care for these patients.

Hospital Payment Systems in the United

States
Medicare, as administered by the Centers for Medicare &
Medicaid Services (CMS), is a federally funded program and is
the major healthcare payment system in the United States.1
Hospitals receive payments using the Acute Care Hospital
Inpatient Prospective Payment System, which classifies
patients into Medicare Severity Diagnosis-Related Groups
(MS-DRGs) to determine payment amounts.2 The hospital is
paid the same dollar amount for each patient in the assigned
MS-DRG regardless of length of stay or resources used during
that stay. Each patient is assigned to an MS-DRG based on his
or her principal diagnosis and the existence of secondary diagnoses, which are known as either major complications or
comorbidities (MCCs) or complications or comorbidities
(CCs). Documentation of these MCCs and/or CCs can change
the MS-DRG to which the patient is assigned; a higher payment is given for MS-DRGs associated with a CC and an even
higher payment for MS-DRGs associated with MCCs.

Scenarios of 2 different patients admitted with the same principal diagnosis can help the clinician understand the implications
of this system.
Patient A is admitted with major chest trauma and requires
mechanical ventilation for 2.5 days. He was well nourished
prior to arrival and does not require tube feeds since he was
extubated and eating an oral diet by day 3. He is discharged
home on day 4.
Patient B is admitted with major chest trauma, requiring
mechanical ventilation. As he lives by himself and has little
access to food due to his financial status, he has lost about 30
pounds over the past 6 months. Due to his preexisting malnutrition and the likelihood for extended time on the ventilator,
enteral nutrition support is started. This patient is seen by the
registered dietitian (RD) to manage the tube feeding, and a
physical therapist helps him recover from deconditioning
experienced in the intensive care unit from being on the
ventilator for 5.5 days. His hospital length of stay is 9 days, and
he is discharged home with a referral to Meals on Wheels.
Although the RD knew the patient was malnourished, she did

From 1Morrison Healthcare, Crozet, Virginia.

Financial disclosure: None declared.
Corresponding Author:
Wendy Phillips, MS, RD, CNSC, CLE, Morrison Healthcare, 5790
Locust Ln, Crozet, VA 22932, USA.
Email: wp4b@virginia.edu

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Nutrition in Clinical Practice XX(X)

Table 1. Example Scenarios for Resource Utilization and Payment Amounts Based on Medical Diagnosis Documentation.
Patient

MS-DRG

Patient A 185, major chest

trauma without
CC or MCC
Patient B 183, major chest
trauma with
MCC

Resources Used During Stay

Mechanical ventilation for 2.5
days
No RD or PT visit
Mechanical ventilation for 5.5
days
RD and PT visits

Length of Stay in
ICU/Hospital, d

RW

Facilitys
BR, $

Payment for this

Patient (RW BR), $

2.5/4

0.70131

$7000

$4909

6/9

1.4695

$7000

$10,286

BR, base rate; CC, complication or comorbidity; ICU, intensive care unit; MCC, major complication or comorbidity; MS-DRG, Medicare Severity
Diagnosis-Related Group; PT, physical therapy; RD, registered dietitian; RW, relative weight.

not document that in the note or ask the physician to document

it, because she was so focused on managing the tube feeds.
Both of these patients would be assigned to the MS-DRG
185, major chest trauma without CC/MCC, based on the principal diagnosis. In the absence of any other comorbidities or
complications being documented by the physician, neither
patient would be increased to a higher severity level DRG.
Therefore, the hospital will be paid the same to care for both
patients, despite the significant increase in resources used by
patient B. If the RD documents severe malnutrition as the
nutrition diagnosis and notifies the physician to document
severe malnutrition as the medical diagnosis, the MS-DRG
would be changed to 183, major chest trauma with MCC,
resulting in a higher payment amount for the care provided to
patient B (see Table 1).
A base rate for payment is developed for each hospital
based on several factors, including but not limited to geography, resident and medical education costs, overhead costs, and
average case mix index (which indicates acuity level of patients
cared for at that institution).2 Each MS-DRG is assigned a relative weight, and this factor is then multiplied by the base rate
for the facility to determine the payment amount for that
patient. Table 1 shows example calculations for the 2 case studies listed; when severe malnutrition is documented appropriately, the payment for patient B would be more than double the
payment for patient A.
In addition to affecting payment rates, documentation of
CCs and MCCs affects the case mix index (CMI).2 The CMI is
the average of the relative weights for MS-DRGs for all
patients admitted to the hospital for a set period of time. As the
CMI is a factor in calculating the base rate, the relative weight
of a patients assigned MS-DRG can affect the current payment, as well as influence the base rate for that facility for the
next year. The level and complexity of services provided at a
hospital can also be estimated by comparing the CMI of one
hospital with another. Hospitals with higher CMIs provide
higher complexity of care.
Only 1 CC or MCC is needed to change the assigned
MS-DRG and therefore the relative weight and payment for
each patient. Therefore, a malnutrition diagnosis may not
always change the actual payment for a patients hospital stay

or the CMI. However, all presenting diagnoses, including malnutrition, need to be documented to be included in the MS-DRG
by the coding department. Medical documentation, including
diagnoses, procedures, and many interventions, are translated
into numerical codes using the International Classification of
Diseases, Ninth Revision (ICD-9).3 The codes are used for billing and research purposes, allowing for standardized documentation that can be recognized by billing software and
queried to find incidence of diseases when conducting research.
ICD-9 codes corresponding to malnutrition are listed in Table
24; as it is anticipated that the United States will be transitioning to the 10th revision of the ICD system soon, the corresponding codes are listed. It is important to note that although
ICD-9 codes are available for use in the United States for
kwashiorkor and marasmus, these conditions are rarely seen in
this country and therefore should rarely be documented and
coded in hospitals. The Office of the Inspector General will
audit the hospital to verify accuracy of code assignment if
these codes are routinely documented as part of the principal or
secondary diagnoses.

Diagnosing and Treating Malnutrition

Although the ICD-9 codes exist for malnutrition, there is no
standardized definition for malnutrition accepted by the CMS
or the Centers for Disease Control and Prevention or any other
agency, or a universally accepted set of signs and symptoms
that indicate the degree of malnutrition. Therefore, the
Academy of Nutrition and Dietetics and the American Society
for Parenteral and Enteral Nutrition (A.S.P.E.N.) formed an
expert workgroup to develop an etiology-based classification
system for malnutrition.5 This system distinguishes between
starvation-related malnutrition, chronic diseaserelated malnutrition, and acute disease or injury-related malnutrition
and helps the clinician determine severity of the malnutrition
(such as moderate or severe). It is recommended that at least 2
of 6 characteristics are evaluated to determine the presence
and severity of the malnutrition. These 6 characteristics are
energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that
may sometimes mask weight loss, and diminished functional

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Phillips

Table 2. ICD-9 and ICD-10 Codes for Malnutrition.

ICD-9 Code

ICD-10 Code

ICD-9 Title
a

260

E40

Kwashiorkor

E42

Kwashiorkora

261

E41

260

E43

263

E44.0

263.1

E44.1

263.2

E45

263.8

E46

263.9

E46

ICD-10 Title
a

Kwashiorkor

Criteria/Description

MCC/CC

Nutritional edema with dyspigmentation of

skin and hair

MCC

Marasmic
kwashiorkora
a
Nutritional marasmus Nutritional marasmusa Nutritional atrophy; severe malnutrition
otherwise stated; severe energy
deficiency
Other severe protein- Unspecified severe
Applicable to:
calorie malnutrition
protein-calorie
Starvation edema
malnutrition
Description synonyms:
T1DM with severe malnutrition
T2DM with severe malnutrition
T1DM with severe diabetic
malnutrition
T2DM with severe diabetic
malnutrition
Edema due to nutrition deficiency
Nutritional edema
Protein calorie malnutrition, severe
Severe malnutrition due to T1DM
Severe malnutrition due to T2DM
Severe protein calorie malnutrition
Severe protein-calorie malnutrition
(Gomez criteria10: less than 60% of
standard weight)
Malnutrition of
Moderate proteinNo definition given
moderate degree
calorie malnutrition
Malnutrition of mild Mild protein-calorie
No definition given
degree
malnutrition
Arrested development Retarded development
following proteinfollowing proteincalorie malnutrition
calorie malnutrition
Other protein-calorie Unspecified proteinSee below
malnutrition
calorie malnutrition
Unspecified protein- Unspecified proteinA disorder caused by a lack of proper
calorie malnutrition
calorie malnutrition
nutrition or an inability to absorb
nutrients from food. An imbalanced
nutrition status resulting from insufficient
intake of nutrients to meet normal
physiological requirement. Inadequate
nutrition resulting from poor diet,
malabsorption, or abnormal nutrient
distribution. The lack of sufficient energy
or protein to meet the bodys metabolic
demands as a result of an inadequate
dietary intake of protein, intake of
poor-quality dietary protein, increased
demands due to disease, or increased
nutrient losses.

MCC

MCC

CC
CC
CC

CC
CC

Adapted with permission from Phillips W. Coding for malnutrition in the adult patient: what the physician needs to know. Pract Gastroenterol.
2014;39:52-60. Available at www.ginutrition.virginia.edu. ICD codes are available at www.cms.gov/icd10. CC, complication or comorbidity; DM,
diabetes mellitus; ICD-9, International Classification of Diseases, Ninth Revision; ICD-10, International Classification of Diseases, 10th Revision;
MCC, major complication or comorbidity; T1DM, type 1 diabetes mellitus; T2DM type 2 diabetes mellitus.
a
Should rarely be used in the United States.

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Nutrition in Clinical Practice XX(X)

status as measured by handgrip strength.5 To ensure malnutrition is diagnosed similarly by RDs, physicians, and all other
healthcare providers at the same facility and between facilities, a standard definition for malnutrition should be developed and implemented at each hospital. The consensus
statement from the Academy of Nutrition and Dietetics and
A.S.P.E.N. can be used as a basis for the facility-specific malnutrition policy.
Patients who are screened as being at risk for malnutrition
through the admission screening process or any other means
should be referred promptly to the RD for a thorough nutrition
assessment and, if warranted, classification of degree of malnutrition using the malnutrition policy as a guide. The RD will
then implement a nutrition care plan in coordination with the
medical care plan as determined by the physician, with appropriate interventions to treat the malnutrition. The RD will follow up on the response to the nutrition care provided during the
hospital stay, making adjustments as necessary, and ensure
nutrition care continues after discharge, with the goal of preventing readmissions for nutrition-related issues. It is important for the physician to also document the degree of
malnutrition as the medical diagnosis, as only physician documentation can be used for inpatient clinical coding by clinical
documentation specialists. The steps for ensuring adequate
documentation of nutrition status by the RD and licensed independent practitioner for use by the clinical documentation specialists are listed in Figure 1.

Paent is idenfied
as malnourished or
at nutrion risk via
nutrion screen.

Referral is made to
registered diean
(RD).

RD performs
thorough nutrion
assessment and
determines degree of
malnutrion.

RD nofies physician
of recommended
diagnosis with
supporng criteria.

If the RD documents
malnutrion but the physician
does not, the clinical
documentaon specialist will
query the physician to see if
he/she agrees with the
malnutrion diagnosis.

Research and Performance Improvement

Although increased payment for providing services is a benefit of accurate documentation and coding of malnutrition, the
ICD system was not originally created for billing and payment
purposes. It was created by the World Health Organization as
a standard classification of disease, injuries, and causes of
death.6 Therefore, the transition to the 10th revision of the
ICD system (commonly known as ICD-10) will be beneficialdue to improved specificity in coding of diagnoses,
research and epidemiological trials healthcare cases can be
tracked more efficiently and accurately, and resource utilization for specific disease states can be more closely monitored.
In addition to using these codes for research and epidemiology, the United States uses the codes for billing purposes
because computer systems talk and interface in numbers,
not words.
A poster from Clinical Nutrition Week 2015, hosted by
A.S.P.E.N., highlighted the importance of adequate documentation and coding related to research and performance improvement efforts.7 A team tracked the numbers of patients seen in
clinic with gastrostomy tube complications, then later ran
reports from the coding system and found that the actual incidence of complications was 240% higher than what was coded.
If later a performance improvement initiative is implemented
in that clinic to determine success at preventing complications

Physician documents the

degree of malnutrion in
his/her own progress
note and/or problem list.

Coders translate the

malnutrion diagnosis from
the physician
documentaon into the
corresponding ICD-9 code.

Figure 1. Steps to include the malnutrition diagnosis in the

Medical Severity Diagnosis-Related Group documentation. ICD9, International Classification of Diseases, Ninth Revision.

without knowing this previous report, it will appear there were

few complications and nothing needs to be done to improve
patient outcomes. Ultimately, it is the future patients who
might have poorer outcomes because the coding was not done
properly. This study highlights a similar problem when comparing actual ICD-9 coding with clinical documentation of
malnutrition diagnoses; the prevalence of malnutrition in acute
care hospitals is higher than that captured in the coding data.8,9
Many examples exist to further demonstrate the importance
of adequately documenting and coding for all disease states
and procedures and complications to constantly improve
patient outcomes. One example involves the determination of
the number of patients readmitted due to dehydration within 30
days of hospital discharge with a feeding tube. The goal is to
request needed dietitian and nurse practitioner staffing to help

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Phillips

manage these tube feeds at home rather than having the patients
get sicker and be readmitted to the hospital. The first step in
completing this project would be to identify all patients with a
feeding tube who were readmitted with dehydration, which is
typically done by searching the clinical database using the ICD
code for dehydration. The research team must be able to trust
that all patients have been coded correctly to capture a representative sample of the patient population. Similarly, if the
goal is to design improvements for nutrition care provided at
the hospital, with a focus on malnourished patients at greatest
risk of morbidity and/or mortality, the first step at identifying
the patient population would be a search of the clinical database using the ICD codes for malnutrition.

Conclusion
All diseases and procedures, as well as diagnoses and causes of
death, must be documented and coded correctly, including malnutrition. Epidemiology depends on accurate documentation
and translation into numerical codes that can be manipulated by
data management systems. The development of a valid and reliable program to identify, document, intervene, and code malnutrition is one of the ways the nutrition support clinician can
contribute to the financial stability of the hospital and enhance
the potential for adequate clinical resources to care for malnourished patients. In addition, classifying a patients degree of malnutrition can help the healthcare team determine how frequently
to reassess the patient and his or her response to care to provide
the best possible outcomes. Accurately documenting the malnutrition diagnosis can also influence the case mix index, indicating the high acuity level of patients treated at the hospital.

Statement of Authorship
Wendy Phillips equally contributed to the conception/design of the
work; contributed to the acquisition, analysis, and interpretation of

the data; drafted the manuscript; and agrees to be fully accountable

for ensuring the integrity and accuracy of the work. The author read
and approved the final manuscript.

References
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Accessed June 10, 2015.

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