Disease-related malnutrition is a common and costly problem in healthcare. An estimated 30% to 50% of hospitalized patients are undernourished. Left untreated, malnutrition can lead to a range of problems, including: increased length of hospital stay, increased postoperative complications, decreased wound healing, and increased mortality. Unfortunately, malnutrition in the hospital setting is often under-recognized and therefore undertreated. Furthermore, the cost of care associated with an undernourished patient is often two to three times higher than a well-nourished patient. Given the change in healthcare reimbursement from a fee-for-service approach to a bundled payment model, it is imperative that healthcare facilities properly identify, treat, and document this condition to ensure adequate compensation is received for the care of these patients.
Acknowledging the shift in payment and the need for accuracy in coding, the Center for Medicare and Medicaid Services (CMS) is moving from the ICD-9 coding system to the ICD-10, and hospitals are expected to implement the new codes by October 1, 2015. The primary difference between the two systems is the increased level of detail provided in the ICD-10 codes: they contain approximately five times as many terms and descriptors than the ICD-9 codes. The coding system expansion will allow healthcare teams to deliver more accurate documentation, leading to an improvement in the quality of care. For malnutrition coding, the higher level of detail in the ICD-10 will enable greater inclusion for nutrition-related complications, therefore ensuring adequate reimbursement for this particular condition. Failure to enforce the ICD-10 codes by the deadline could result in a decrease in overall reimbursement for patient care.
Recognizing Malnutrition in the Hospital Setting: Best Practices
What processes can hospitals introduce in the clinical area to ensure that the malnourished patient is properly identified, assessed, and treated, and that care is accurately documented to maximize reimbursement levels? Several cost-effective methods to identify and treat malnutrition will simultaneously decrease hospital expenses and increase revenues. These techniques include: using a validated screening tool and following the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Academy of Nutrition and Dietetics (Academy) consensus statement on adult malnutrition to identify malnourished patients, and adopting the Nutrition Care Process (NCP) to assess patients and implement an appropriate plan of care. In conjunction, these three tools are essential in accurately identifying, treating, and coding for malnutrition.
Employing a proven resource such as the Malnutrition Screening Tool (MST) is the first step in pinpointing this condition. The MST is a quick, easy, and reliable test that can be completed during the nursing evaluation process. The consensus statement developed by the Academy and A.S.P.E.N. uses standardized diagnostic characteristics to detect adult malnutrition. The tool was created using evidence-based data to recognize and diagnose this condition.
The second step is confirming that your clinical nutrition team is executing the NCP—a four-step process used to categorize nutrition-related problems. The NCP employs standardized language to describe the nutrition diagnosis, intervention, monitoring, and evaluation processes. Additionally, the use of consistent terminology improves the quality of communication between the clinical nutrition and general healthcare team members so they can initiate the most appropriate plan of care.
It is essential for the clinical and coding teams to collaborate to properly identify patients who meet the malnutrition criteria. Successful implementation of this process can lead to significant boosts in revenue. Facilities with an average daily census of 100+ reported over $300K gained from proper malnutrition coding. While applying the correct protocol takes time, it will ultimately lead to greater identification of the malnourished patient and therefore improved reimbursement, which will enable allocation of the appropriate resources to better care for the malnourished patient.
- 1. Jensen GL, Compher C, Sullivan DH, Mullin GE. Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. JPEN J Parenter Enteral Nutr. 2013;37(6):802-807.
- 2. Cobb B, Hardin E, Click A, Watson L. Customizing Malnutrition Documentation Accelerates Hospital Revenue and RD Value. J Am Diet Assoc. 2011;111(9 Suppl):A77.
- 3. White JV, Guenter P, Jensen G, Malone A, Schofield M; Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112(5):730-738.
- 4. Recognizing Malnutrition in Adults: Definitions and Characteristics, Screening, Assessment, and Team Approach [PDF] Authors: Gordon L. Jensen, Charlene Compher, Dennis H. Sullivan, Gerard E. Mullin
- 5. Customizing Malnutrition Documentation Accelerates Hospital Revenue and RD Value Author(s): B. Cobb, E. Hardin, A. Click, L. Watson; Food & Nutrition, Decatur General Hospital – Morrison Management Specialists, Decatur, AL
- 6. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) Jane V. White, PhD, RD, FADA; Peggi Guenter, PhD, RN; Gordon Jensen, MD, PhD, FASPEN; Ainsley Malone, MS, RD, CNSC; Marsha Schofield, MS, RD; the Academy Malnutrition Work Group; the A.S.P.E.N. Malnutrition Task Force; and the A.S.P.E.N. Board of Directors