Wednesday, October 25, 2017

The Importance of Properly Documenting Malnutrition States

Malnutrition is a very common condition in the hospitalized patient. Up to 40% of the hospitalized patients can have some degree of malnutrition (1), and, severe malnutrition can rage between 8.4 and 21.4% (2,3). Surprisingly, in spite of being so common, this condition is one of the most under-documented conditions. 

This condition, if present, is associated with worse outcomes than if not present. A poorly nourished body will respond poorly to infection and other insults through a weakened immune system. The extracellular and intracellular compartments become depleted of electrolytes and other substances essential for the proper functioning of tissues. All this translates into a state associated with higher severity of illness and risk of mortality.

Making sure that malnutrition is properly documented and  stratified, i.e, specifying mild moderate or severe, is key for the following reasons:

- It helps seeking proper reimbursement for resources consumed in the care of this condition.
- It would accurately reflect severity of Illness (SOI) and risk of mortality (ROM).
- Quality measures such as observed/expected mortality rates and risk adjusted mortality rates are influenced by the presence or absence of malnutrition.

The ASPEN Criteria are an accepted way of identifying malnutrition and staging it. They rely on history to obtain information regarding weight and loss of food intake, they use the physical exam to describe the loss of muscle and adipose tissue, the presence of edema and the reduction of handgrip strength. Variables such as albumin and pre albumin and measurements such as weight are not considered diagnostic criteria. 

The fact that malnutrition is an under-documented condition may be a driver for increasing the queries for that diagnosis. in order to avoid fraud and abuse, it is critical to keep a high quality of the query, consistent with policies and regulations. The queries always need to be supported by the right clinical indicators and have to be non-leading. The dietitian’s evaluation is a valuable document that will help with queries and communication with providers.

In conclusion, malnutrition is very common, it is under-documented and it is related to poor medical outcomes. Documenting malnutrition impacts quality reporting and improves reimbursement. The ASPEN criteria are used to diagnose it and, in order to avoid fraud and abuse, queries have to be thoroughly supported.

Marco A. Ramos MD, CCDS


1. Barker LA, Gout BS, Crowe TC. Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. International Journal of Environmental Research and Public Health. 2011;8(2):514-527. 
2. Rocandio AM, Arroyo M, Ansotegui L. Assessment of nutritional status on hospital admission: nutritional score. European Journal of Clinical Nutrition 2003; 57: 824–831. 
3. Constans T, Bacq Y, Brechot JF, Guilmot JL, Choutet P, Lamisse F. Protein-energy malnutrition in elderly medical patients. Journal of the American Geriatric Society.1992;40:263–8.

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