Dietitians: Driving Revenue & Value in Hospital Malnutrition Care

November 16, 2021

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

There is no secret about the impact malnutrition has on patient outcomes. It is well known that dietitians add value via medical nutrition therapy for patients. One area that often gets overlooked is how dietitians add value by working to positively impact the patient and the hospital’s financial implications when treating malnutrition. 

So, how do we link the value of patient care provided by dietitians to the financial bottom line?

Let’s start by explaining how the payor system works in the hospital setting.

Billing and coding are essential to the healthcare revenue cycle processes. They are the processes which translate a patient encounter into the languages used for claims submission and reimbursement.¹

According to CMS, a hospital’s case mix index (CMI) represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.² 

Hospital costs associated with malnutrition are related to the average length of stay. Medicare establishes the expected average length of stay based on the final Medicare Severity-Diagnosis Related Group (MS-DRG).³

So, how do we link the value of patient care provided by dietitians to the financial bottom line?

When malnutrition is identified, coded, and treated appropriately, the assigned MS-DRG may change, indicating a longer expected length of stay, thus, more appropriately capturing the resource requirements associated with providing care for malnourished patients.³

There are five ICD-10-CM codes for malnutrition that have been designated as either a major complication/co-morbidity (MCC) or complication/co-morbidity (CC) under the MS-DRG system.⁴ , ⁵

ICD-10 CodeDescription
E43Unspecified severe protein-calorie malnutrition (MCC)
E44.0Moderate protein-calorie malnutrition (CC)
E44.1Mild protein-calorie malnutrition (CC)
E45*Retarded development following protein-calorie malnutrition (CC)
E46Unspecified protein-calorie malnutrition (CC)
  * Used in pediatric population


A major complication/comorbidity (MCC) or complication/co-morbidity (CC) may result in a higher Medicare payment to account for more intense levels of care and/or longer lengths of stay.³

Here is an example of the financial impact of properly diagnosing, documenting, and coding malnutrition care for a patient.

In order for hospitals to bill for the treatment of malnutrition on the basis of the severity of the condition (mild, moderate, or severe) and qualify for increased reimbursement from Medicare, a medical diagnosis by the physician must be accompanied by a plan of care that was implemented during the hospitalization.⁶ The plan of care for patients generally requires alignment between the dietitian and physician in malnutrition severity level with supporting evidence (e.g. AND/A.S.P.E.N. malnutrition criteria) and individualized nutrition interventions that are documented as part of the treatment plan.

Since ICD terminology fails to incorporate the impact of the inflammatory response on nutrition diagnosis, assessment and treatment, in 2012, the Academy and A.S.P.E.N. delineated an initial set of clinical characteristics to facilitate the standardized recognition and documentation of adult malnutrition by dietitians, Primary Care Providers (PCPs) and other members of the health care team (AND/A.S.P.E.N. malnutrition criteria).³ 

Dietitians play a critical role as the nutrition experts in utilizing clinical judgment along with the AND/A.S.P.E.N. malnutrition criteria to assess and document critical pieces of information used by PCPs, facility-based coders and others to validate a diagnosis of adult malnutrition (MS-DRG). Dietitians also provide medical nutrition therapy based interventions to improve the patient’s outcomes.

Tying it all together.

As a result of improvements in malnutrition diagnosis capture initiated by dietitians, hospitals may see a positive impact on their overall case mix index (CMI). 

CMI is a key performance indicator for the hospital’s overall performance and clinical documentation practices. Having higher case mix index values indicate that a hospital has treated a greater number of complex, resource-intensive patients, and the hospital will be reimbursed at a higher rate.⁷

Conclusion: Yes, dietitians are a revenue generating department in the hospital setting.

References (Accessed on 10/06/2021):

¹ Trends in RDN knowledge and patterns of coding, billing and payment
² Case Mix Index
³Consensus Statement of the Academy of Nutrition and Dietetics/A.S.P.E.N.: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) (J Acad Nutr Diet. 2012; 112: 730-738
⁴ Common Diagnoses (ICD-10-CM) Codes Related to Nutrition Services
⁵ Center for Medicare and Medicaid Services 2017 ICD-10-CM and GEMs
⁶ State Operations Manual, Center for Medicare and Medicaid Services
⁷ What is case mix index (CMI)\#:~:text=This%20measure%20reflects%20the%20diversity,reimbursed%20at%20a%20higher%20rat


For Academy of Nutrition and Dietetics Members, more information can be found in the “Malnutrition Codes - Characteristics and Sentinel Markers” section.

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