As people age, the body’s ability to absorb food diminishes. Morbidity and medication use can also affect nutrition status, leading to poor health in older adults. Physicians who care for the elderly need to identify, diagnose and treat malnutrition while addressing the primary illness. Comprehensive clinical documentation and access to reliable medical billing and coding services are crucial to ensure optimal reimbursement for services rendered.
As aco-morbidity, malnutrition increases the length of stay and costs of care, including rehabilitation costs. A 2016 study in Science Direct revealed that:
- Older Americans face high risks for malnutrition and loss of lean body mass.
- Malnutrition affects up to 60% of older adults in the hospital setting.
- In many cases, malnutrition among the elderly goes unrecognized and untreated.
- Malnutrition can negatively impact overall health and recovery.
- Nurses play a key role in identifying malnutrition and malnutrition risk.
To provide the best nutrition interventions and maximize outcomes, and also receive reimbursement for the additional care provided, physicians, nurses and registered dieticians (RDs) need to be knowledgeable about the criteria to recognize and document malnutrition and ensure compliant and accurate medical coding. This is especially challenging as there are stringent Medicare regulations and specificities associated with different care environments which affect coding and documentation of malnutrition in the elderly.
Malnutrition can be mild, moderate, or severe. According to the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines, the presence of two or more of the following characteristics can help in the diagnosis of adult malnutrition:
- Insufficient energy intake
- Weight loss
- Loss of muscle mass
- Loss of subcutaneous fat
- Localized or generalized fluid accumulation
- Diminished functional status as measured by hand grip strength
Medical coding service providers can help clinicians submit claims with accurate ICD-10 coding to report diagnosis of malnutrition in elderly patients. The ICD-10 codes for malnutrition are as follows:
E40 – Nutritional edema with dyspigmentation of skin and hair (kwashiokar should rarely be used in the U.S.)
E42 – Severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus
E41 – Nutritional atrophy; severe malnutrition otherwise stated; severe energy deficiency (Nutritional marasmus should rarely be used in the U.S.)
E43 – Unspecified severe protein-calorie malnutrition (nutritional edema without mention of dyspigmentation of skin and hair)
E44 – Moderate protein calorie malnutrition
E44.1 – Mild protein-caloriemalnutrition
E45 – Retarded development following protein calorie malnutrition
E46 – Unspecified protein calorie malnutrition
E64 – Sequelae of protein calorie malnutrition
Comprehensive clinical documentation is critical to assign the right codes for nutrition/malnutrition. Documentation should include: history and clinical diagnosis, clinical signs and physical exam, anthropometric information, results of lab tests, dietary data, and functional outcomes. When assessing patients, physicians also need to watch out for the prevalence of major complications or comorbidities (MCCs), or complications or comorbidities (CCs) strongly associated with malnutrition, such as pancreatic cancer, lung cancer, head and neck cancer, gastrointestinal cancer, stroke, and COPD.
An article on coding challenges in geriatrics published in Today’s Geriatric Medicine in 2011 cited a senior compliance specialist with Cancer Treatment Centers of America, a national network of hospitals providing cancer treatment as saying, “The efficiency of coding and billing is the efficiency of documentation. There are physicians who are good documenters and those who are not. As we move into ICD-10 and healthcare reform, we’re going to find out that documentation is key”. The expert notes that not doing it right the first time will lead to lost money and increased risks for individual practices.
An expert from the Nutrition Systems, University of Virginia Health System, Charlottesville, VA, makes some important observations about coding for malnutrition in the adult patient:
- Under the Medicare Severity-Diagnostic Related Groups (MS-DRGs) established by the Centers for Medicare and Medicaid Services (CMS), patients with the same diagnosis and similar clinical characteristics are assigned to an MS-DRG and the hospital is paid a fixed amount based on the average cost of care for patients in that group. Reimbursement is higher for MS-DRGs associated with a CC, and an even higher for MS-DRGs associated with MCCs.
- Efficient communication between the RD and physician is necessary during the patient’s hospitalization. For instance, if malnutrition is documented by the RD in his/her assessment, but the physician does not include malnutrition as a medical diagnosis, the medical coding company may need to send a query to the physician to confirm the latter’s agreement with RD’s diagnosis. Proper communication can reduce the need for such queries.
- While three malnutrition diagnosis codes qualify as MCCs (kwashiorkor, nutritional marasmus, and severe protein calorie malnutrition), kwashiorkor and marasmus are rarely prevalent among adults in the U.S. Therefore these codes should rarely be used to document malnutrition. A hospital that routinely includes these codes as part of the principal or secondary diagnoses for the patient faces a high risk of an audit by the Office of the Inspector General (OIG) to verify the accuracy of the code assignment.
With comprehensive clinical documentation, expert coders in reliable medical billing companies can ensure the use of the right codes so that geriatric physicians receive the highest level of reimbursement when treating malnutrition in elderly patients. The support of an experienced medical billing and coding service provider can prevent denials and ensure timely payments.