As our understanding of the effects of malnutrition on outcomes and hospital stays has evolved, it has become increasingly important for the Registered Dietitian Nutritionist (RDN) to consistently identify and communicate the degree of malnutrition present in any patient who meets criteria, in order to set up a timely treatment plan. The clinical nutrition team is positioned to spearhead the education of all appropriate providers to ensure consistent use of the approved criteria throughout the facility. This article aims to provide practical guidance for clinicians to do just that.
Malnutrition has been associated with trends toward higher acuity, higher health care cost, and poor patient outcomes. However, until recently no universal definition of malnutrition was available. As our understanding of the effects of malnutrition on outcomes and hospital stays has evolved, it has become increasingly important for the Registered Dietitian Nutritionist (RDN) to consistently identify and communicate the degree of malnutrition present in any patient who meets criteria, in order to set up a timely treatment plan. Adopting and imbedding standard language related to malnutrition in the electronic medical record (EMR) can lead to more consistent coding and tracking.
Wendy Phillips, MS, RD, CNSC, CLE, FAND, Division Director of Clinical Nutrition, Morrison Healthcare, St. George, UT Maria Browning MS, RD, CNSC, Quality Expert, Charge Management Surgical Charge Optimization Revenue Cycle Services, IU Health Methodist Hospital, Indianapolis, IN
Most healthcare professionals will agree that malnutrition can be simply defined as inadequate calories, protein, and micronutrients required for proper tissue growth, maintenance, and repair.1 The causes of malnutrition can be multifactorial including, but not limited to: poor nutrient intake, malabsorption, poor nutrient utilization (hyperglycemia), and/or hypercatabolism. Historically, malnutrition has had various descriptions in the literature due to the lack of a universally accepted definition. Therefore, the prevalence of malnutrition in hospitalized patients has been reported to be anywhere between 16-68%.2-7 Regardless of the definition used, malnutrition is associated with poorer outcome,8 specifically: longer hospital length of stay,4-14 more readmissions within 30 days,14-29 more nosocomial infections,16-29 and more pressure injuries.24-27 Unfortunately, due to the various definitions found in the literature describing the prevalence of, and complications associated with, malnutrition, the true prevalence and consequences are still unknown.
The Academy of Nutrition and Dietetics (Academy) and the American Society for Enteral and Parenteral Nutrition (A.S.P.E.N.) joined forces to develop a consensus statement for the identification of adult malnutrition in 20121 and for pediatric malnutrition in 2014.28 Clinicians and researchers are encouraged to use the criteria set forth from these documents to identify malnutrition in an effort to inform facility policies, interventions, and resource allocations. It would help the process of standardizing definitions of malnutrition if each facility reviews and approves the Academy/A.S.P.E.N. criteria for malnutrition assessment and diagnosis by all key players: clinical nutrition team, LIPs, and coders. The clinical nutrition team is positioned to spearhead the education of all appropriate providers to ensure consistent use of the approved criteria throughout the facility. This article aims to provide practical guidance for clinicians to do just that.
Malnutrition Coding: Beyond the Money
Understanding the Medicare payment structure for hospital admissions is necessary to understand the importance of adequately diagnosing malnutrition and translating the malnutrition diagnosis into International Classification of Disease (ICD), 10th revision (ICD- 10) codes.30 Medicare is the largest funding source for most hospitals, and some commercial insurance companies structure their payment system similar to Medicare. Medicare does not pay hospitals directly for each expense incurred to care for patients, but rather categorizes patients into a Diagnosis Related Grouping (DRG) based on the principle diagnosis precipitating hospitalization.31 Payment is then based on an annual analysis of the average resources required to care for patients admitted for the same or similar principle diagnoses. Additional stratification occurs when the patient is further categorized into tiers within the DRG based on the presence of secondary diagnoses. This stratification is known as the Medicare Severity-DRG (MS-DRG) – some DRGs have one or two tiers, but the majority have three. Secondary diagnoses are those impacting clinical evaluation, therapeutic treatment or diagnostic procedures, and extend the length of stay or increase the nursing care required. They can be coded as co-morbidities or complications (CCs) or major co-morbidities or complications (MCC). See Table 1 for definition of terms. CCs and MCCs can raise the assigned tier within the DRG for the patient’s principle diagnosis. Medicare reimbursement increases to the hospital for higher tiered patient stays in order to cover the increased cost of care. Since the higher tiers have a higher relative weight (RW) assigned by Medicare, this also influences the case mix index (CMI).31 The CMI is an average of all of the RWs of patients with discharges within a specified time interval, and provides an index of the severity level of the patient population receiving care at that hospital. The CMI will also influence the base rate for that hospital for Medicare payment in subsequent years.
Secondary diagnoses count as CCs or MCCs and influence payments for hospital stays under Medicare’s MS-DRG Inpatient Prospective Payment System only if several conditions are met and documented in the licensed independent practitioner (LIP) progress notes.31 The secondary diagnosis cannot be an integral part of the principle admitting disease process itself and must affect the care provided during that hospital admission. For example, severe protein-calorie malnutrition cannot be considered a MCC for the principle diagnosis of “Failure to Thrive” because the two conditions are too similar. For principle diagnoses in which severe protein-calorie malnutrition could be listed as a MCC, there must be documentation demonstrating additional nursing care or other resources required for the patient (such as enteral or parenteral nutrition support). While clinicians recognize malnourished patients require additional resources and nursing care, this is not always clearly stated in the medical record, nor historically been adjusted for in terms of hospital reimbursement. Secondary diagnoses must be listed in the final diagnostic statement by the provider using whatever method the facility has designated (such as the problem list or the discharge History and Physical). For example, a patient may be admitted with community-acquired pneumonia as the principle diagnosis precipitating hospitalization. Secondary diagnoses may include acute respiratory failure (requiring the intervention of mechanical ventilation) and severe protein-calorie malnutrition (requiring the intervention of enteral nutrition). The acute respiratory failure and severe protein-calorie malnutrition would be listed as secondary diagnoses by the LIP in the final diagnostic statement and coded to be included in the MS-DRG assignment.
Although both acute respiratory failure and severe protein-calorie malnutrition are MCCs, only one MCC is required to increase the severity tier of the DRG. Therefore, the malnutrition cannot be considered a diagnosis that increases reimbursement in this patient, because the acute respiratory failure would have already increased the DRG and the reimbursement, even if malnutrition had not been documented and coded. However, both should be documented and coded. Beyond potentially increasing the reimbursement for providing care, the accurate identification, documentation, and coding of malnutrition is important for many other reasons. First, it encourages an increased awareness and focus on malnutrition that requires a specific intervention during that encounter and throughout the transition of care. When malnutrition is documented as a medical diagnosis and communicated through the discharge summary alerting clinicians at the next care site (such as a rehabilitation or long term care facility), prompt attention to nutrition care needs will be more likely to occur within that next setting.
Additionally, the expected length of stay (LOS), severity of illness (SOI), and risk of mortality (ROM) increase as the secondary diagnoses are coded as CCs or MCCs and the patient moves to a higher tier within the MS-DRG.31 This provides more realistic survival expectations for Medicare and other payers who use a method similar to the MS-DRG classifications. “Grades” that are given to a hospital and individual providers based on patient outcomes are adjusted for SOI, ROM, and CMI. The adjustment process is too complicated to explain in this article; a basic explanation is that coding for all applicable secondary diagnoses (like malnutrition) can make the hospital or provider’s grades better with the same outcomes because of the associated expected SOI and ROM. A good grade with a high CMI is an overt indication that the facility successfully cares for very ill patients. Poor grades may cause payers to remove the hospital or LIP as a provider for certain payment plans. This data is also publicly available, and patients may not seek care from institutions whose survival rates are below what is expected for a particular diagnosis. Diligence in documenting an MCC such as severe protein-calorie malnutrition not only can move the patient’s stay to a higher tier within the MS-DRG, which has the potential to direct nutrition intervention as well as help recover revenue for services, but also better represents SOI, ROM, and the resources required to care for the patient.
Finally, large-scale epidemiological studies require accurate diagnosis data available in discrete fields in the electronic medical record (EMR) that can be queried by automated data mining programs. Standardized language to describe the diagnosis of malnutrition with associated signs and symptoms ensures the interoperability and communication for that diagnosis with different EMRs, billing systems, and data mining programs used for research. An example of discrete fields would be the utilization of flow sheets with drop-down boxes that have been pre-populated with standardized language that can be clicked indicating the presence and degree of malnutrition.
Malnutrition Treatment: It Takes a Healthcare Village
The first step in identifying malnutrition in the hospitalized patient is through adequate nutrition risk screening, which is usually conducted by the registered nurse as part of the admission screening process. A validated nutrition screening tool appropriate for the patient population is recommended, such as the Malnutrition Screening Tool,32 the Malnutrition Universal Screening Tool,33 or the Nutrition Risk Screening (NRS) 2002.34 Periodically, the accuracy of the screening tool and the workflow process to notify the RDN should be reevaluated to ensure patients requiring full nutrition assessment and interventions are being identified.35,36
Once a patient is identified as at-risk for malnutrition, or frankly malnourished, either through the nutrition screening process or other method, a referral needs to be placed to a registered dietitian nutritionist (RDN) to complete a full nutrition assessment and implement a nutrition care plan in partnership with the patient/ caregiver, physician, nurses, and other healthcare team members. RDNs rely heavily on nursing documentation to evaluate the parameters described in the malnutrition clinical characteristics consensus statements published by the Academy/A.S.P.E.N.1,28 The RDN must communicate the presence of malnutrition and the associated signs and symptoms to the LIP responsible for the care of the patient; this will need to be included as a medical diagnosis by the LIP. This crucial step ensures the diagnosis is communicated from one care setting to the next so that nutrition intervention continues until the malnutrition is resolved.
The nutrition interventions in the care plan should specifically address the etiology, as well as signs and symptoms of the malnutrition. Often, nursing and food service staff will assist with the actual implementation of the nutrition interventions designed by the RDN, with nursing staff providing valuable documentation in the medical record about the patient’s response to care.
In some facilities, the LIP will need to place orders for at least some of the nutrition interventions per facility policy. The RDN will monitor, evaluate, and document the patient’s response to care, progress towards defined goals, making alterations to the nutrition care plan as needed, and finally document and coordinate the discharge nutrition needs to ensure appropriate nutrition follow-up after leaving the hospital.
Physicians continue to be responsible for documenting all diagnoses affecting the hospitalization or influencing the principle diagnosis causing the patient’s admission. If a patient is malnourished, this will affect the course of the hospital stay, the resources necessary to care for the patient, and the length of hospitalization required.9-14 Therefore, malnutrition should be documented by the LIP responsible for the care of the patient whenever it has been identified by the RDN as a nutrition diagnosis.
Likewise, medical billing specialists are required to code for all diagnoses affecting the care of the patient and/or their prognosis during that hospital stay, regardless of whether or not doing so will influence reimbursement for the stay. If the RDN has provided written information about the malnutrition as a nutrition diagnosis, but the LIP has not added it also as a medical diagnosis, then the billing specialist should query the LIP to check for agreement with the RDN. He/she may also query the RDN for documentation clarification if necessary.
Documentation Guidance for RDNs and LIPs
Since the malnutrition diagnosis must be documented by the LIP for it to become part of the official record of care from one healthcare facility to the next, RDNs need effective communication strategies to notify the LIP when a patient is identified as malnourished. Ideas to accomplish this are included in Table 2. A suggested sample charting template for RDNs is included in Table 3 with ideas on how this can coordinate with the LIP’s documentation. Documentation must be sufficiently detailed and measurable, and specific to the patient to support Medicare billing compliance audits that may be conducted by Medicare’s Recovery Audit Contractors or the Office of the Inspector General. See Table 4 with examples for specific and measurable documentation.
Building the Foundation: Success Story of Documentation
Streamlining and standardizing the documentation process as described above can lead to drastic improvements in identifying all degrees of malnutrition within the hospital setting. In 2013, Indiana University (IU) Health identified a significant opportunity to improve the diagnosis of malnutrition at their Adult Academic Health Center (AHC). The AHC consists of 2 major hospitals including: level one trauma services, comprehensive transplant services, the largest neurosurgery center in the state, and destination care for all ranges of oncology services, as well as many others. Despite providing high-level care for acute and chronically ill patients, in 2013, malnutrition was coded as a secondary diagnosis in only 5.5% of patients discharged from the 2 facilities combined.37 As a process improvement intervention, standardized language using the malnutrition clinical characteristics criteria from the consensus statement1 was developed and imbedded within the EMR in 2014 allowing the clinical nutrition team to unify their approach to the diagnosis of malnutrition Additionally, with the support of IU Health Information Services and the Statewide Advanced Provider Team, approval was gained to allow for RDN documentation to automatically populate LIP documentation. Within the first year of implementation, total patients discharged with a diagnosis of malnutrition increased from 2900 to 4969 encounters, a 71% increase. More specifically, severe protein-calorie malnutrition diagnoses increased from 459 to 2081 encounters, a 353% increase. Ultimately, the end result was an increase in total discharges with a malnutrition diagnosis from 5.5% to 10%.37
The increased number of discharges with a malnutrition diagnosis led to improved communication of the nutritional state of the patient and required interventions implemented to remedy the malnutrition in the transition of care from the acute care hospital to home, long term care facility, or inpatient rehabilitation facility.
Consistent with previous studies,7,12 the costs associated with treating malnourished patients were higher in IU Health’s population. Despite making up only 6% of the population, patients diagnosed with malnutrition made up nearly 12% of the total variable direct cost for patients admitted during a 30-day period (Table 5). Therefore, increasing awareness of the prevalence of malnutrition and the associated necessary interventions to treat it is an important step towards reducing overall healthcare costs.
CONCLUSION/CALL TO ACTION
Focusing on nutrition assessment, diagnosis, documentation, and intervention led to a significant improvement in identifying patients at nutrition risk requiring intervention at IU Health. Continued attention must be given by the entire healthcare team to ensure ongoing success. It is essential for RDNs to be diligent in their role to identify malnutrition, communicate with the LIP and other healthcare team members, and most importantly, implement meaningful interventions. Patients identified with malnutrition during their hospital stay should have clear instructions for continued nutrition repletion communicated to all appropriate healthcare team members and documented in the discharge summary. Standardizing how malnutrition is defined and documented with details specific to the individual patient will help facilities move towards meaningful and effective assessment, diagnosis, and intervention. In order to conduct studies within and beyond our own institutional walls, RDNs should agree to use the standards as defined by the Academy/A.S.P.E.N. Consensus Statements of 2012 (adults)1 and 2014 (pediatrics)28 and build this into daily practice. First and foremost the goal is to improve care and patient outcomes, benefiting not only the patient and families, but also the providers and institutions. Consistent documentation and coding leads to a better understanding of disease through the ability to mine large amounts of data to determine which diagnoses are most often comorbidities of each other and the related implications. Correlating malnutrition with quality metrics such as length of stay, blood stream infections, wound healing, anthropometrics, readmission and mortality will allow for improved understanding of implications and lead to more targeted therapy. An understanding of population health determinants requires appropriate documentation and coding of protein-calorie malnutrition to inform populated based interventions. Acknowledements A special thank you to Kate Willcutts, DCN, RD, CNSC, University of Virginia Medical Center, Charlottesville, VA and Terese Scollard, MBA RDN LD FAND, Providence Health and Services, Portland, Oregon, for their expertise and editorial suggestions.