The diagnosis of malnutrition is under high scrutiny by Medicare

 

By Christine C Stallkamp MD FAAFP, System medical director, Revenue Integrity and Care Coordination

 

The diagnosis of malnutrition is often made with support of the nutrition team, using a national guideline, called ASPEN criteria.  Once the diagnosis is made, the physician must document the diagnosis and plan for treating the malnutrition. Other clinical findings, such as cachexia, weight loss over a defined period of time, BMI, hypo-albuminemia, muscle wasting, etc, must be documented as well to support the diagnosis. Further, documentation explaining how the malnutrition is impacting medical decision-making is key.

 

In the face of audits by Medicare and commercial payors, MLH must ensure proper assignment of the malnutrition diagnosis.  Please consider the following points when documenting malnutrition:

  • If you think your patient has a diagnosis of malnutrition, please consult the nutrition team to help you confirm the diagnosis, if they are not already on the case.
  • Use clear, recurrent documentation of malnutrition in progress notes, once the diagnosis is made. If you answer a query for malnutrition, this alone is not enough to support the diagnosis under potential audits.
  • Include daily documentation of how the malnutrition is being monitored and treated, and include it as a diagnosis on the discharge summary.
  • Support the diagnosis by including signs and symptoms of malnutrition in your daily notes.
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