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Last Modified: 4/19/2024 Location: FL, PR, USVI Business: Part A

Coding guidelines: Part A inpatient billing for malnutrition diagnosis codes

The following information provides billing guidelines for severe protein calorie malnutrition when billed during an inpatient admission.

Severe protein calorie malnutrition

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

ICD-10 Codes for Malnutrition

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

Resources

Additional information
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.
CMS guidelines:

For additional information on the DRG validation review process:

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 external link
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