Complication or Comorbidity( CC), depending on coding guidelines and the patient ' s overall clinical circumstances. Appropriate documentation can therefore increase case severity and ensure reimbursement more accurately reflects the resources required to care for these complex patients. Hospitals devote substantial resources to nutrition assessment, monitoring and intervention and failure to document malnutrition appropriately can result in underrepresentation of resource utilization and financial losses.
To support accurate coding, documentation should clearly specify the severity of malnutrition, such as mild, moderate, severe, or severe protein-calorie malnutrition and should be based on validated clinical criteria. In the United States, many organizations utilize the Academy of Nutrition and Dietetics / American Society for Parenteral and Enteral Nutrition( ASPEN) criteria, which assess characteristics such as inadequate energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, fluid accumulation and diminished functional status. Provider documentation should reflect the clinical assessment and incorporate dietitian findings when appropriate.
ASPEN Criteria:( conveniently located in the RD assessment *)
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation
• Reduced functional status
* Please check the RD assessment to capture the correct diagnosis for problem list documentation. This will minimize additional queries.
In conclusion, appropriately documenting malnutrition is a critical clinical responsibility that supports timely nutritional treatment, improves patient outcomes, accurately reflects disease severity, enhances quality reporting and ensures appropriate reimbursement.
Jason Knight, MD, MBA CMO Renown Regional
Renown Health | Physician Pulse Newsletter | 5