Reporting malnutrition

Documenting malnutrition as a secondary diagnosis helps establish the severity of an underlying illness, improves publicly reported data, and can increase reimbursement to the hospital. In general, secondary diagnoses are reportable if they affect patient care in terms of clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or nursing care and/or monitoring. In many cases, impaired nutritional status is considered significant enough to impact the severity of illness, the resulting length of stay and the cost of care in the acute care setting.

The coder must pay special attention to diagnoses considered to be complications and comorbidities (CCs), or major complications and comorbidities (MCCs). These increase the patient's illness severity, and thus the MS-DRG payment to the hospital. An MCC reflects the highest level of severity for a secondary diagnosis, and results in increased use of hospital resources. MCCs for nutrition include severe malnutrition, protein malnutrition and emaciation. CCs result in increased hospital resource use as well, but to a lesser extent than MCCs. CC diagnoses include unspecified malnutrition, protein-energy undernutrition, cachexia, and body mass index less than 19 kg/m2 (see for definitions of diagnoses).

Art 1

Non-CCs, while reportable as secondary diagnoses, don't increase the use of resources or impact MS-DRG reimbursement. They include mild or moderate malnutrition and failure to thrive.

Case Study

A patient was recently treated for pneumonia and is now admitted to the hospital with weakness and diarrhea that is found to be due to Clostridium difficile colitis. Laboratory results show a serum albumin level of 2.3 g/dL; nursing has recorded a BMI of 16 kg/m2. A dietary evaluation finds that the patient is at 70% of normal body weight. Nutritional supplements and vitamins have been prescribed and given.

The following scenarios illustrate the impact of nutrition terminology on MS-DRG assignment, as shown by the reimbursement for this case. All scenarios are based on a hospital-specific rate of $5,500.

Scenario 1

  • Principal diagnosis: C. diff. colitis.
  • Secondary diagnosis: Failure to thrive.
  • MS-DRG 373, major GI diagnosis without CC/MCC: $4,777.

Scenario 2

  • Principal diagnosis: C. diff. colitis.
  • Secondary diagnosis: Failure to thrive, and BMI less than 16 kg/m2 as documented by dietitian or physician.
  • MS-DRG 372, major GI diagnosis with CC: $7,191.

Scenario 3

  • Principal diagnosis: C. diff. colitis.
  • Secondary diagnosis: Failure to thrive, and severe malnutrition.
  • MS-DRG 371, major GI diagnosis with MCC: $10,530.