I read with great disappointment and concern the article “Malnutrition revisited” by coding columnist Richard D. Pinson, MD, FACP, in the January 2017 ACP Hospitalist.
I would agree that accurate coding data and adequate evidence to support it are critical for medical coders and to help direct patient care improvement and patient safety efforts. This article, however, provokes doubt and confusion rather than clarity about sincere efforts to collect accurate evidence to support diagnosis and coding of protein-calorie malnutrition as described in the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition 2012 Consensus.
As the article states, ICD-10-CM codes of moderate and severe protein-calorie malnutrition do not differentiate among acute, chronic, or social or environmental circumstances. The ICD-10 therefore addresses only severity and not current clinical knowledge describing malnutrition types. Use of the code E63.9, as the article suggested, is therefore completely unhelpful as it does not differentiate types nor does it elevate the seriousness of severe or moderate types. There is great difference clinically. Treatment and intervention are safely determined only with knowledge of the type of malnutrition.
The metabolic state greatly impacts feeding regimens and the ratios and timing of nutrient combinations. Delivered incorrectly, inappropriate nutrient ratios can cause death and metabolic imbalances. The severity and type of malnutrition are therefore both critical pieces of clinical information and should not be dismissed to a single non-MCC or non-CC code.
Many professionals have spent careers trying to better understand nutrition diseases and to clarify diagnoses in order to enable diagnosis and coding for an honest evidence-based assessment of the extent of malnutrition, all to better act and intervene at appropriate levels with our limited resources. This article does not recognize the depth of this effort and these clinical findings.
Terese M. Scollard, MBA, RDN, LD
Note: Ms. Scollard is a contributor to Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition 2012 Consensus and her opinions do not necessarily reflect positions of her employers or professional organizations.
Dr. Pinson responds: I thank Ms. Scollard for her letter, and I certainly appreciate her point of view. Malnutrition has always had diagnostic, therapeutic, and coding challenges. As I mentioned in my column, while much of the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition 2012 Consensus has merit, I have concerns about its subjectivity, certain inconsistencies, and potential compliance risks, and I believe my column properly discussed these concerns. In my view, a critical, rational analysis of any proposed new definitions and criteria is valuable. I look forward to future debate, discussion, and research on this issue that may address both my and Ms. Scollard's concerns.