Putting Malnutrition Diagnoses Under the Microscope

September 14, 2021

Tips for Documenting Findings (And Preparing for Audits)

By Ashley Matthews, MS, RD, LD, CNSC, PMP, Head of Clinical Excellence, Junum

There has been a lot of discussion lately around accurately coding for malnutrition. Just last year, the Office of Inspector General released a report casting doubt on hospitals’ ability to accurately document and diagnose this insidious condition.

Naturally, the Centers for Medicare and Medicaid Services (CMS) is paying attention and continues to conduct audits accordingly. And importantly, in recent listening sessions, members of the CMS Provider Compliance Division (CPD) met with members of ASPEN, the Academy, ASN and ACDIS to hear their concerns about improper denials and disputed criteria used by auditors. (This blog post from the director of ACDIS goes into more detail.)

In the end, CMS’ focus on malnutrition is good news. Nearly 30% of patients admitted to hospitals are at risk of malnutrition, but <7% are diagnosed.¹ The more focus this pervasive condition receives, the better. Still, audits can be nerve wracking and may even lead dietitians to second-guess their findings.

It is important to accurately document findings of malnutrition and evidence of treatment. Quality of care — and accurate reimbursements — often depend on it. So here are some tips to help you be more confident in your documentation and diagnoses.

Standardize Your Criteria
Whether your hospital uses AND/ASPEN, Merck Manual or GLIM criteria, it’s a good idea to choose one set of criteria and use it consistently. Clinical nutrition leaders should work with hospital leadership to standardize on a set of criteria based on modern, evidence-based standards, and make sure all providers and CDI team members are on board. Getting everyone on the same page can greatly reduce the burden placed on your coders, along with simplifying communication between providers and dietitians.

Audit Yourself
Do your process improvement initiatives address malnutrition? The time to evaluate your processes is now — before external auditors do it for you. You can start today by auditing your workflows to make sure all pertinent team members are using the malnutrition diagnosis information from the chart in their documentation.

Train and Train Again on the Nutrition-Focused Physical Exam
Regular training can keep new hires and long-term staff working from the same playbook when it comes to this critical exam. Now, you may be thinking these exams take too much time to conduct with all patients. Fair enough — but sound policies and procedures can help your team consistently identify patients who should have a full nutrition-focused physical exam and those who are well nourished enough to forego it.

Own Your Value and Enter the Room
The COVID-19 pandemic has prevented many dietitians from entering patient rooms. At some hospitals, other care team members are doing their best to gather the information dietitians need to assess a patient and document their findings. However, dietitians should also be empowered to assert their value as essential staff alongside nurses and physicians. One way to do this is to find ways to enter patient rooms (if PPE is available) and do a physical assessment.

And remember, Junum can help you simplify documentation, diagnosis and communication between dietitians and physicians. Our clinician-driven technology helps dietitians document signs and symptoms of malnutrition, select a severity level and alert physicians — all within existing EHR workflows. Contact us today and discover what better malnutrition diagnoses could mean for your hospital.


¹ Barrett ML, Bailey MK, Owens PL. Non-maternal and Non-neonatal Inpatient Stays in the United States Involving Malnutrition, 2016. ONLINE. August 30, 2018. U.S. Agency for Healthcare Research and Quality. Available: www.hcup-us.ahrq.gov/reports.jsp

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