Avoid assumptions when coding malnutrition

Malnutrition is at its most basic level any nutritional imbalance. It can be overnutrition, such as being overweight, obese, or morbidly obese. On the other end of the spectrum are patients who are undernourished, which is a continuum of inadequate intake and/or increased requirements, impaired absorption, altered transport, and altered nutrient utilization.

 

Malnutrition is an underdiagnosed condition, especially in the inpatient population, according to James S. Kennedy, MD, CCS, president of CDIMD in Smyrna, Tenn.

 

The guidelines for reporting malnutrition changed in 2012. The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) say malnutrition should be diagnosed when at least two or more of the following six characteristics are identified:

ASPEN and the Academy no longer believe that albumin and pre-albumin and similar biometrics are useful indicators for malnutrition, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla. 

 

“The reason being that they all are actually what we call acute phase reactants, meaning that they're falsely lowered in patients who have inflammation, even if that inflammation is chronic or very subtle,” Haik says. “A patient with just merely starvation has inflammation, so the other tests we can do actually show inflammation.”

 

From a clinical perspective, if a patient has more than two of the six elements in the appropriate clinical setting, then malnutrition may be present, Haik says.

The article also includes three levels of inflammatory state:

Notice that the Academy and ASPEN do not differentiate between mild and moderate malnutrition, Kennedy says.

 

Marasmus is a state in which virtually all available body fat stores have been exhausted due to starvation.

 

Conditions that produce marasmus in developed countries tend to be chronic and indolent, such as cancer, chronic pulmonary disease, and anorexia nervosa.

 

Kwashiorkor is an acute form of protein-energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates.

 

It occurs mainly in connection with acute, life-threatening illnesses such as trauma and sepsis, and chronic illnesses that involve acute-phase inflammatory responses.

 

Coders should not report ICD-9-CM code 260 (Kwashiorkor) when a physician only states moderate protein malnutrition, Haik says. The physician must actually state kwashiorkor before coders can report it. See Coding Clinic, Third Quarter 2009, p. 6.   

 

The World Health Organization now calls kwashiorkor “severe acute malnutrition.”

Both marasmus (ICD-9-CM code 261) and kwashiorkor are MCCs, so coding either of these conditions will lead to a higher-weighted MS-DRG.

 

Both conditions are very rare in the United States and coders and clinical documentation improvement specialists should discuss the validity of the terms with physicians, Kennedy says. “The interaction between coders, physicians, and dieticians is very important.”

 

Physicians may also document sarcopenia, the loss of muscle mass and muscle strength.

Emaciation is a phenomenally wasted condition of the body, Kennedy says. In coding terms, emaciation falls under code 261.

 

Cachexia is a multifactorial syndrome characterized by severe body weight, fat, and muscle loss, and increased protein catabolism due to underlying disease(s). Cachexia is to be considered the result of the complex interplay between underlying disease, disease-related metabolic alterations, and,
in some cases, the reduced availability of nutrients.

 

Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, and composition), function, and clinical outcome.

 

Even when the physician documents cachexia, the physician must also document whether the patient is malnourished, Kennedy says.

 

Coders will more often see an actual diagnosis of mild, moderate, or severe malnutrition instead of cachexia, says Mindy Hamilton, RD, LD, a registered dietitian from Kansas City, Mo. Cachexia may be present, but the patient could be a 90-year-old woman who lives alone, doesn’t take in a lot of food, and still gets the nutrients that she needs.

 

ICD-9-CM includes a code for cachexia due to malnutrition--799.4. However, the physician still needs to document the term malnutrition and its severity, Kennedy says.

 

In the ICD-9-CM Index to Diseases, the term deficiency does not automatically default to malnutrition, Kennedy says. Coders need to look for specific adjectives in order to choose the correct ICD-9-CM code:

“A dietary deficiency in and of itself is not malnutrition unless the adjectives protein deficiency or nutritional deficiency are added to it,” Kennedy says. “We need to be very sensitive that the word deficiency is there and certainly the validity of the code is part of the joint effort between the doctor and the coder.”

 

Coders report food deprivation by itself with code 994.2 (effects of hunger). Just because the physician writes starvation doesn’t mean the coder can assume the patient is malnourished, Kennedy says. The physician must define and document the malnutrition.

 

Coders can locate the appropriate code for the degree of malnutrition by looking up Malnutrition, degree, or by looking for the specific degree, such as:

Note that malnutrition following gastrointestinal surgery is not included in the 260-263 code range, Kennedy says. Coders should use ICD-9-CM code 579.3.

 

If a physician documents “moderate-severe malnutrition,” coders or CDI specialists must query the physician to determine which term applies, according to Coding Clinic, Third Quarter 2012, p. 10. If the answer is “severe,” assign code 261. If the answer is “moderate,” assign code 263.0 (malnutrition of moderate degree).

 

“We cannot code that documentation unless we query the physician,” Kennedy says. The answer will affect MS-DRG assignment because 261 is an MCC, while 263.0 is only a CC.

 

Coders should also notice that ICD-9-CM does not include any degrees of protein malnutrition, unlike protein-calorie malnutrition, Kennedy says.

 

If a physician documents “moderate protein malnutrition,” coders should report code 263 series, even though that is not in the index, Kennedy says. See Coding Clinic, Third Quarter 2009, p. 6. Coders should query the physician for additional specificity if the physician documents moderate protein malnutrition.