The following information provides billing guidelines for severe protein calorie malnutrition when billed during an inpatient admission.
Malnutrition is a broad term used to describe undernutrition.
Diagnosis is usually based on patient history with clinical indications documented in the medical record:
To determine severity:
BMI, serum albumin, total lymphocyte count, CD4+ count, serum transferrin.
To diagnose complications and consequences:
Complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), glucose, calcium, magnesium, phosphate.
Physical examination to include:
Measurement of height and weight
Inspection of body fat distribution
Anthropometric measurements of lean body mass.
BMI calculated to determine severity.
History and clinical diagnosis:
Demonstrates risk for severe malnutrition.
Physical exam/clinical signs:
It can reveal the presence of several of the diagnostic characteristics of malnutrition such as weight loss or gain, fluid retention, loss of muscle or fat, and other signs of specific macro- and/or micronutrient deficiencies.
Coders must keep the ICD-10-CM official guidelines for coding and reporting in mind when coding malnutrition.
For reimbursement, malnutrition must be identified, diagnosed, documented, and treated by the physician while providing care for the primary illness.
Conditions that may support the diagnosis of severe malnutrition:
Disorders that affect gastrointestinal (GI) function (interference with digestion, absorption, or lymphatic transport of nutrients):
Pancreatic insufficiency
Enteritis
Enteropathy
Retroperitoneal fibrosis
Milroy disease
Wasting disorders: catabolism causes cytokine excess, resulting in undernutrition via anorexia and cachexia (wasting of muscle and fat)
Decrease in appetite or impairment of metabolism of nutrients:
Acquired immune deficiency syndrome (AIDS)
Cancer
Chronic obstructive pulmonary disease (COPD)
Renal and heart failure
Conditions that increase metabolic demands:
Hyperthyroidism
Pheochromocytoma
Burns
Trauma
Critical illnesses
Signs may include:
Weight loss:
10% of body weight lost
Starved adults may lose up to 50% of their normal body weight
BMI under 18.5
Obvious significant muscle wasting, loss of subcutaneous fat
Nutritional intake of < 50% of recommended intake for two weeks or more (as assessed by the dietician)
Bedridden or otherwise significantly reduced functional capacity
Weight loss of > 2% in one week, 5% in a month, or 7.5% in three months
Include labs and clinical findings
When billing malnutrition codes for an inpatient hospital stay, hospitals should perform the DRG validation review process, review related coding review practices, as well as verify medical record documentation supports the malnutrition code billed on the claim.
DRG validation is performed to ensure that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the beneficiary's medical record. Reviewers shall validate principal diagnosis, secondary diagnoses, and procedures potentially affecting the DRG.
(Not an all-inclusive listing)
ICD-10 code |
ICD-10 description |
Criteria |
Major complication or comorbidity (MCC) or complication or comorbidity (CC) |
E40 |
Kwashiorkor |
Severe malnutrition with nutritional edema with dyspigmentation of the skin and hair. Kwashiorkor should rarely by used in the US. |
MCC |
E41 |
Nutritional marasmus |
Severe malnutrition with marasmus. Nutritional marasmus should rarely be used in the US. |
MCC |
E43 |
Unspecified severe protein-calorie malnutrition |
Starvation edema. |
MCC |
E44.0 |
Moderate protein-calorie malnutrition |
No criteria given. |
CC |
E44.1 |
Mild protein-calorie malnutrition |
No criteria given. |
CC |
E45 |
Retarded development following protein-calorie malnutrition |
Nutritional short stature, nutritional stunting, or physical retardation due to malnutrition. |
CC |
E64.0 |
Sequelae of malnutrition and other nutritional deficiencies |
Code first condition resulting from (sequelae) of malnutrition and other nutritional deficiencies. |
CC |
CMS representatives have participated in multiple multi-stakeholder discussions regarding opportunities available to advance malnutrition care quality.
The Malnutrition Quality Improvement Initiative (MQii) is a project of the Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders who provided expert input through a collaborative partnership. This initiative aims to advance evidence-based, high-quality, and patient-driven care for hospitalized older adults who are malnourished or at-risk for malnutrition.
Novitas resources:
Additionally refer to:
Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims OIG Report
A-03-17-00010