Q&A: Validating malnutrition diagnosis with RD note

Q: For inpatient hospital code reporting purposes, is the physician’s co-signature at the bottom of the registered dietitian’s (RD) note—where the dietitian includes clinical assessment, a diagnosis of severe malnutrition, and treatment plans associated with the diagnosis—sufficient to assign E43 if there is no other documentation of the diagnosis, but also no conflicting documentation that would refute what the dietitian noted? 

A: This is a great question. Speaking very technically, the provider who signs the RD note in agreement with the findings is acceptable for coding purposes but not best practice, especially when it comes to this diagnosis.

At a minimum, the provider should sign the note with a statement that they agree with the assessment and is implementing recommendations. However, for coding purposes, clear and consistent documentation is necessary. A “one and done” documented diagnosis is vulnerable to denials for this reason alone. If you are seeing denials from a coding standpoint, more than likely this statement from the Official Guidelines for Coding and Reporting is used:

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

What also may be added to the denial rationale from a coding standpoint comes from the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, which advises, “A query should be considered when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent.”

From a clinical standpoint, there are a few issues with this specific diagnosis. Typically, hospitals use the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to diagnose malnutrition as well as the severity of malnutrition. Payers will typically use the Global Leadership Initiative on Malnutrition (GLIM) criteria. If a patient meets ASPEN criteria for severe malnutrition of chronic disease or socioeconomic reasons, they typically will meet GLIM criteria as well. However, the pain point is usually when documenting severe malnutrition of acute disease. Most often, patients meet this criterion due to an acute weight loss and reduced intake in a short period of time (usually within a week’s time). But this same population may not meet GLIM criteria.

Which brings us to the next hurdle: treatment. The Office of Inspector General’s audit of severe malnutrition for the past two years has given us some insight. The problem isn’t that the patients aren’t meeting specific criteria, but that there is no significantly focused treatment, inpatient follow-up, and/or plan for outpatient follow-up. Patients don’t need to be on enteral feedings or tPA, but only prescribing multivitamins does not scream malnutrition.

Nursing documentation does play a key role in supporting this diagnosis. If a patient is diagnosed with any degree of malnutrition, wouldn’t you at least expect this to be part of the nursing care plan? Something as simple as this indicates malnutrition is a focus of care. Documentation of daily weights, percentage of meals eaten, and calorie counts all provide evidence that malnutrition is a focus of care and is being addressed on a daily basis. Nursing documentation that simply shows 100% of every meal is consumed does not support a malnutrition diagnosis (unless for socioeconomic reasons).

The provider should also include how effective the ordered treatment is. This diagnosis is no different than any other diagnosis. Although the RDs are specialists, it is the provider who needs to come up with a treatment plan and evaluate the effectiveness of the treatment. RDs are stretched thin and do not evaluate patients on a daily basis with this diagnosis. Although they schedule a visit three days after the initial assessment, the patient more often than not is discharged before the next scheduled visit occurs.

At the time of discharge, the discharge summary should include a plan once the patient is discharged from the hospital, as malnutrition is not going to resolve in a week or two. It can be something as simple as a weight check with a primary care physician, a social services consultation, or an outpatient nutritionist consultation for the follow-up visit.

Another consideration is the patient’s underlying disease process. Cancer patients are typically hypercatabolic and are at significant risk for malnutrition. A patient with end-stage chronic obstructive pulmonary disease may not be able to eat and breathe, and so skips meals. Usually, the RD does include these elements in their assessment, but so should the provider.

I know we are trying to unburden providers, but in this case, clear and consistent documentation of the problem, strategy, and plan is essential for validation. It is not enough that the patient meets specific criteria. The focus of malnutrition validation is, “What did we do about it?” Documentation for this diagnosis needs to go the extra mile.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.