MALNUTRITION DIAGNOSIS

PROCESS
Concord Hospital

Abstract
The process of identifying and diagnosing malnutrition from initial screening to billing

Lanier, Taelin (Taelin.Lanier@ksc.keene.edu)

Dietetic Internship 2017
Screen and Screening Tools
Both DTR and RD screen patients to assess their level of acuity using the guidelines of
the Concord Hospital Nutrition Screening Form from Policy and Procedure Manager (Image 1).
o Not at risk 0 pts
o Low risk 1 pt
o Moderate risk 2 pts
o High risk 3+ pts
Patients with 3 or more risk points are identified as high nutritional risk, ranked as a level
one, and further seen by the RD for a full assessment. The RD assess the patient for
malnutrition using the ASPEN guidelines for clinical malnutrition (Image 2). Malnourished
patients can be identified as mild or moderate/severe and acute or chronic. Each have their own
ICD-10 title and billing code.
o Code E44- moderate protein- calorie malnutrition- CC
o Code E44-1 mild Protein- calorie malnutrition - CC
o Code E43- Unspecified severe protein-calorie malnutrition- MCC
o Code E46- Unspecified severe protein-calorie malnutrition- CC

MDC 10 Endocrine, Nutritional & Metabolic Diseases & Disorders. Nutritional and Miscellaneous
Metabolic Disorders https://www.cms.gov/icd10manual/fullcode_cms/P0237.html

Documentation and Communication to the Hospitalist

The findings are recorded in four places by the RDN: 1) The nutrition shift-note documented
in the hospital medical record database, McKesson. 2)the Malnutrition Order form. 3) The
Acuity Board in the RD office has a total number of all patients diagnosed with malnutrition and
this number is also input into the excel document where the RDNs patient tracking is
documented.
To communicate these findings to the MD, the RDN places the Malnutrition Order sheet in
the patients chart book under the Progress Notes tab. Attached is a Sign here sticky note
where the MD must initial and date the order. They must then include the comorbidity in the
patients diagnosis list and their discharge summary. This diagnosis is also mentioned at floor
rounds to the entire patient care team by the RDN.

Tools for Documentation

If severe protein-calorie malnutrition is noted, the doctor includes this diagnosis in the
patients next progress notes. This is usually hand written on a blank sheet that says Progress
Notes at the top. For the time the patient is in the hospital, the malnutrition sheet with the RDN
and hospitalists signature will remain in the chart book for reference. The physician must include
malnutrition in the patients diagnosis and discharge summery in Horizon Expert Orders (our
ordering and prognosis server). With the diagnosis they must include an intervention. If not an
intervention by the M.D., then at least a note stating the RDN is providing appropriate care and
to refer to their notes. This can then be billed and will show up in their medical records. This
cannot be printed. The Malnutrition Order Form can be found in Image 2.

Communication to Coding
The malnutrition sheet that we fill out is sent to billing. After they document it, they
send it to coding. Coding then selects the correct ICD-10 number.

Malnutrition, Billing and Revenue

Malnutrition, moderate or severe, is billed by the hospital. Depending on the insurance,
plan, deductible, and medical diagnosis, the bill may be an itemized nutrition expense list or
include it in the patients total bill. Obesity comorbidity (BMI>40) and underweight (BMI <18.5)
are also billed by the hospital.
Since malnutrition and other comorbidities increases the patients severity of illness (SOI)
index, the diagnosis of this health-related issue increases the patients bill and thus the hospitals
revenue. These comorbidities must be documented and capture because they most likely
increase the patients care needs and extend their stay.
Recording malnutrition in high-nutrition risk patients has contributed revenue for the
hospital. For each comorbidity form filled out, the hospital receives approximately $1000. In
March 2017, 317 Malnutrition orders were done. This equates to approximately $317,000.
Moderate malnutrition costs the patient $1000, major malnutrition costs $4,000, and BMI costs
$500. When malnutrition is found in conjunction with other diagnosis such as pneumonia or a
cardiac issue, the hospital receives an extra $2,500. Since not every comorbidity form gets
entered or accepted, they estimate that each form provides between $1000-$1400. This
contributes to hospital income. Never Events (hospital acquired conditions, falls, etc.) do not
get paid for. Malnutrition, even if developed in hospital, is not a Never Event.

Reimbursement
Steps needed for reimbursement of malnutrition include completing the BMI or
malnutrition order sheet with the dietitians and physicians signature, documenting this actions
digitally by the RD in the shift note, and including this diagnosis in the patients diagnosis and
discharge summary by the physician.
Whether or not the hospital gets reimbursed is dependent of the patients insurance. They
are the deciding factor for what is covered and what is not. For Medicare and Anthum, almost
all nutrition related diagnoses are covered.
 For documentation of malnutrition, underweight or obesity, the patient must be registered
as inpatient status, as opposed to observation or outpatient in a bed. They also have to agree to
a nutrition focus physical assessment (NFPA). If the patient declines a NFPA after repeated
attempts by different staff and does not have two other sings of malnutrition, then the process
is documented in the charts and communicated to the health care team.

The Role of the RDN

After the DTR identifies a pt. as a level 1, the RD conducts a full assessment which
includes screening questions regarding: weight history, PO intake, abnormal GI symptoms and a
diet recall, and performs a nutrition focus physical assessment. If identified as malnourished,
she fills out the Malnutrition Order form, signs it, adds the sticky note and places it in the
patients chart book. She then documents this process in the medical server shift-notes and
mentions it at floor rounds. The number of total malnourished patients is updated on the RD
acuity board as well as in their computer-based patient tracker. The RD takes no part in the
billing of the malnourished patient. However, it is within the best of her abilities to ensure the
team did their best when trying to assess for malnutrition.

Appendix

Image 1
Image 2