Q&A: Documentation and ICD-10-CM coding for severe malnutrition

Q: What clinical information can be used to support the reported diagnosis of severe malnutrition and how would this be coded in ICD-10-CM?

A: To meet the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for severe malnutrition in an acute care setting, a patient must present the following symptoms:

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• Energy intake: less than (<) 50% estimates energy requirement for greater than (>) five days
• Weight loss (% of body weight):
  • >2% in one week; or
  • >5% in one month; or
  • >7.5% in three months
• Muscle mass loss: moderate
• Body fat loss: moderate
• Edema masking weight loss: moderate to severe
• Reduced grip strength: measurably reduced

Coding professionals would use ICD-10-CM code E43 to report unspecified severe protein-calorie malnutrition, also known as starvation edema. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus (this diagnosis should be rarely seen in the United States).

While most healthcare facilities still follow the previous ASPEN criteria, in 2018 ASPEN joined with the European Society for Clinical Nutrition and Metabolism, the Latin American Nutritional Federation, and the Parenteral and Enteral Nutrition Society of Asia to publish “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community,” in the Journal of Parenteral and Enteral Nutrition.

The GLIM malnutrition criteria are outlined below.

Phenotypic criteria

Weight loss % (unintended)

5% < six months, or 10% > six months

Low body mass index (BMI)

< 20 if < 70 years, or < 22 if > 70 years

Reduced muscle mass

Reduced by objective measures and/or physical exam

Etiologic criteria

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Reduced nutritional intake

< 50% of requirement for > one week, or any reduction greater than > two weeks, or chronic GI disorders with adverse nutrition impact

Inflammation

Chronic disease, or acute disease/injury with severe systemic inflammation, or socio-economic/environmental starvation

Under the new criteria, severity of malnutrition is based on phenotypic criteria only, and requires one phenotypic criterion that meets these thresholds:

Moderate (stage 1) malnutrition

Severe (stage 2) malnutrition

Weight loss % (unintended)

5%-10% < six months, or

10%-20% > six months

> 10% < six months, or > 20% > six months

Low BMI

< 20 if < 70 years, or < 22 if > 70 years

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< 18.5 if < 70 years, or < 20 if > 70 years

Reduced muscle mass

Mild-to-moderate deficit (per validated assessment methods*)

Severe deficit

(per validated assessment methods*)

From a coding perspective, GLIM identifies only moderate and severe malnutrition. Malnutrition stage is not an indexed term, so if Stage 1 is documented, code E46 (unspecified malnutrition) may be used. If only Stage 2 is documented, it must be clarified as severe for correct coding of the condition.

At this time, the ASPEN criteria are still being followed in the U.S. However, the standard clinical criteria for diagnosing severe malnutrition are actively evolving. ACDIS suggests organizations work to define standardized criteria for use by clinicians, including physicians and dieticians, as well as CDI and coding staff.

Malnutrition has been identified as an audit target by the Office of the Inspector General (OIG), as well as many private payer entities. In July 2020, the OIG published a report identifying that hospitals were incorrectly reporting severe malnutrition to the degree of approximately $1 billion dollars in overpayments for FYs 2016 and 2017.

Although this determination has been challenged at a number of levels, the fact that the OIG made this determination has influenced an increased need for clinical support of malnutrition, especially severe protein calorie malnutrition. The documentation should be reviewed to assure consistent application of the diagnostic criteria used and treatment of the condition are evident.

Consistency within the record is important. For example, templates that state “well nourished” in the patient’s history or presentation should not be followed with documentation of the presence of malnutrition. There should also be consistency amongst the documentation of all clinicians and providers to demonstrate the presence of malnutrition and its associated severity.

The OIG report also spoke to the needed presence of treatment. For example, they expect that the patient’s length of stay or the treatment plan would be affected by the malnutrition diagnosis. The treatment applied should be reflective of the level of severity of malnutrition to include plans to address the nutritional status and the competing etiologies during the hospital stay and post discharge.

Concurrent CDI reviews should address any inconsistencies within the record. Supportive provider documentation should include the appropriate clinical indicators in support of the diagnosis and plan of care to address the nutritional status.

Editor’s note: This Q&A was originally published in September 2019 and has been reviewed and updated to reflect current guidelines and best practice. It originally appeared in Revenue Cycle Advisor and was answered by Richard Pinson, MD, FACP, CCS, during the ACDIS/HCPro webinar, “GLIM: New Global Malnutrition Definition and Its Impact on Coding and CDI.”

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