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I was asked on twitter: Is malnutrition worth it? Does the reimbursement cover the costs of registered dietitians, multivitamins, supplements, etc?

It's one of the top diagnoses that insurances deny (aka not pay for), so that should give you some insight. Severe protein-calorie malnutrition is an MCC, meaning it will move a DRG to the "top tier." (Learn more about what that means here). But is there a dollar amount we can attribute?

The U.S. Department of Health and Human services Office of Inspector General (aka “The OIG”), works to identify, audit and investigate fraud, waste, etc. They audit hospitals, target a certain diagnosis using a sample of patients, determine if that hospital incorrectly over-diagnosed (or under-treated) that condition, and then extrapolate that data to determine how much that hospital was overpaid by Medicare - and then ask that hospital to refund that amount (often millions of dollars).

A 2020 report stated:

Based on that report, the dollar / diagnosis amount is $5,574 per severe protein-calorie malnutrition diagnosis. Revenue cycle professionals will know that’s an oversimplification and it’s unique to each hospital… but it’s a ballpark estimate.

But is that the wrong question? And how did we get here?

Malnutrition is associated with significant increases in morbidity and mortality in the hospital:

• 10.2% increased risk of complications

• Increased length of stay (Average 2 - 3 days)

• 14% Increased risk of readmission

• Higher risk of infections and dying from those infections

• 2.1 times higher risk of pressure ulcers

  (to name a few)

These are the reasons we should be identifying and treating malnutrition early, not for financial gain.

But prior to 2012, there was no standard definition of malnutrition (And Kwashiorkor, a condition that typically only affects children in developing countries in periods of famine, was being frequently coded as a diagnosis for adults in U.S. Hospitals.)

Thus, a workgroup was created and formed the ASPEN criteria. In the below table, TWO factors (left column) must be present for a malnutrition diagnosis:

But show physicians the ASPEN criteria and their heads spin. Many are not comfortable formally diagnosing degrees of malnutrition - we just aren’t formally trained on it like COPD, heart failure, cancer, etc.

Physicians would likely prefer the GLIM criteria, which is simpler and more clinically intuitive:

Although albumin & pre-albumin are not mentioned in the ASPEN criteria as these proteins do NOT change in response to changes in nutrient intake, they, along with CRP, are considered markers of disease burden / inflammation in GLIM.

Regardless of which criterion you prefer, as evident by Vidant health’s remarkable win against the OIG, it’s imperative that hospitals have a robust clinical workflow that

1. Uses nutritional screens and a multidisciplinary approach involving registered dietitians.

2. Consistently uses a validated criterion.

3. Accurately documents the factors met of that criterion.

4. And documents and implements the treatment plan.

Treatment should be more intense for severely malnourished patients. As Pinson & Tang recommend, this treatment may include:

• 2 - 3 daily liquid supplements

• Daily calorie counts, frequent weighing

• Appetite stimulants

• Frequent follow-up with a nutritionist or other healthcare providers

• Lab monitoring (electrolytes such as phosphate and potassium)

• Parenteral or enteral nutrition (noting that enteral nutrition may be used for other non-malnutrition conditions such as dysphagia)

So what can physicians / APPs do?

STOP auto-populating “well developed” and “well-nourished” in your physical exams. This gives room for insurances to deny the presence of and payment for the malnutrition diagnoses. AND it could put you in a position of explaining the legitimacy of your diagnosis to a judge while explaining you, “just used a template…”

Describe malnutrition in your physical exam when you see it:

• Temporal wasting

• Prominent bones such as clavicles, ribs, etc

• Interosseous muscle loss

• Sunken eyes / loss of orbital fat pads

• Brittle hair

• Ridged or cracked nails, etc

Consult RD’s early if you suspect malnutrition. BMI’s less than 19, weight loss, loss of appetite, or cachectic patients should all be triggers.

I often include a “place holder” diagnosis such as “BMI less than 19” or “Loss of appetite” while I consult the RD, make a formal diagnosis, and determine the degree of malnutrition. Essentially, don’t throw around the terms moderate and severe malnutrition all willy-nilly.

In your note, make sure to include the severity of malnutrition, treatment, follow up AND carry it through to your discharge summary.

Cachexia and malnutrition are separate diagnoses. So, document both if present.

Minding Malnutrition

Understand the impact malnutrition has on your patients.

Identify it and get specialists, especially RD’s, on board early.

Clearly document the physical exam findings, diagnosis and treatment so insurances, or the OIG, don’t come calling.

Thanks to Katherine Kopfler, RD, Dr. Benjamin Freda, Dr. Vaughn Matacale for their assistance with this newsletter issue.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Cut note-writing time by >50%

• Prevent medical errors by using notes to stay organized

• Become real-world ready by structuring your notes for billing

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