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For several years now, claims with diagnosis codes for malnutrition have come under the scrutiny of recovery audit contractors (RACs) and other regulatory auditors. The most recent headline involved a payment of nearly $800,000 for Good Samaritan Hospital to settle accusations of False Claims Act violations related to code 260 (Kwashiorkor, a rare protein deficiency resulting in edema and dyspigmentation of skin and hair, typically seen in sub-Saharan nations but not in the United States).

When announcing the above settlement, the Department of Justice issued a press release that included two “red flags” about the Good Samaritan case that provide educational opportunities for others about malnutrition codes and documentation.

Two Lessons

The DOJ alleged that on inpatient claims the hospital added malnutrition as a secondary diagnosis when it was not warranted. Falsely coding inpatient cases with secondary diagno­ses of malnutrition caused the patient profile to appear at a higher level of acuity than it was in actuality. This, in turn, increased the reimburse­ment rate the hospital received.

To warrant this assignment, the physician would have actually had to document a diagnosis of Kwashiorkor. If he or she had included “protein malnutrition” without further specificity in the documentation, the ICD-9 index would lead to code 260.

If the physician documents “severe malnutrition” but does not specify protein-calorie, the code assignment, according to the ICD-9-CM index and tabular instructions, would be MCC 261 (nutritional marasmus). This may not be the physician’s intended diagnosis and/or clinically supported—hence the importance of specificity in the documentation and the need to query the physician based on clinical indicators.

However, be careful about the wording of the query.Good Samaritan “used leading questions so that physicians would answer that the patient was malnourished.” Hospital coders must be aware and comply with the following key points about queries.

  • It may be appropriate to query when documentation in the medical record is illegible, incomplete, unclear, inconsistent, and/or lacks precision.
  • The query should not introduce new information into the record but should contain patient-specific clinical evidence.
  • In general, query forms should not be designed to ask yes/no questions unless they are related to whether or not a condition was present on admission (POA).  The form also should not be designed so that only a signature is required.
  • Multiple choice query formats that employ checkboxes may be used as long as all clinically reasonable choices are listed. The choices should also include an “other” option, with a line that allows the provider to add free text. Providers should also be given the choice of “unable to determine.” This format is designed to make multiple choice questions as open-ended as possible.
  • Individuals performing the query function are expected to follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance. 

Know the Codes

The following are the current ICD-9 codes for malnutrition. Most include a designation of major complication and comorbidity (MCC) or complication and comorbidity (CC). Both designations demand higher payments with MCCs being the highest.

260 Kwashiorkor (MCC)

261 Nutritional marasmus (MCC)

262 Other severe, protein-calorie malnutrition (MCC)

263.0 Malnutrition of moderate degree (CC proposed for fiscal year 2013)

263.1 Malnutrition of mild degree (CC proposed for fiscal year 2013)

263.2 Arrested development following protein-calorie malnutrition (CC)

263.8 Other protein-calorie malnutrition (CC)

263.9 Unspecified protein-calorie malnutrition (CC)

However, as Melinda Tully notes in a May 16, 2012, RACmonitor article (Malnutrition: Documentation for Compliance and Clinical Accuracy), “The existing codes for malnutrition are outdated and do not accurately denote current standards of care or clinical diagnoses related to malnutrition. This results in inconsistent coding, compliance risks and inaccurate clinical data…” (For the article, go to http://racmonitor.com/news/27-rac-enews/820-malnutrition-documentation-for-compliance-and-clinical-accuracy.html.)

Another issue relates to “coding from the index.” Even though coding professionals know not to assign a code from the ICD-9-CM Index of Diseases alone, that is exactly what often happens—and could lead to inappropriate code assignment. Information in the tabular list and the “includes” and “excludes” instructional notes or Coding Clinic for ICD-9-CM should be considered.


Look for the Evidence

One of the main problems is inadequate documentation, says Sandra Routhier, senior healthcare consultant with Panacea Healthcare Solutions, Inc., St. Paul, MN.

“The documentation provided must clinically support malnutrition, and it often doesn’t,” Routhier says. “The physician might have documented malnutrition as a diagnosis but he or she doesn’t provide any clinical evidence of it in the chart. Certain criteria must be present.”

To resolve that problem, hospitals should develop documentation guidelines and clinical criteria for the different severity levels of malnutrition. These guidelines should not, of course, be developed in a vacuum or devoid of physician input. In fact, physicians as well as registered dieticians, coding professionals, and clinical documentation specialists also should be involved.

Fortunately, national associations, including the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition Clinical Characteristics, have developed criteria that may be used to identify a diagnosis of malnutrition. (See the Nutrition Care Manual at www.nutritioncaremanual.org.)

Clinical evidence that supports the diagnosis of malnutrition includes signs and symptoms, findings, and treatments. Evidence also includes the following:

  • Body mass index (BMI)
  • Weight changes (pounds or percent gained and over what time period)
  • Dietary intake or challenges
  • Physical findings (wasting of muscle, debility)
  • Test results (albumin, pre-albumin)
  • Digestive difficulties
  • Absorption problems
  • Eating disorders
  • Supplements (oral, tube feedings, total parenteral nutrition [TPN]).

When there are concerns about the patient’s nutritional status, Routhier would like to see physicians refer to the nutritional assessment for the criteria that supports the specificity (type of nutrition and severity of it) of the nutrition-related diagnosis (like they refer to X-rays, lab reports, and other diagnostic tests).

Oftentimes, she says, “Physicians might document that a patient is malnourished but do not provide an order for the condition to be monitored or treated by a diet change, nutritional supplements or other interventions.”

The goal is to have the medical record documentation support the definition of a secondary diagnosis.  For reporting purposes, the ICD-9-CM Official Guidelines for Coding and Reporting, Section III, define “other diagnoses” as additional conditions that affect patient care in terms of requiring:

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of hospital stay
  • Increased nursing care and/or monitoring.

Item ll-b in the Uniform Hospital Discharge Data Set (UHDDS) defines “other diagnoses” as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.”

Further Study Required

It’s obvious from the above information that malnutrition is a condition that requires further study by coders and documenting physicians alike. The more specificity provided, the more accurate the code that can be assigned—and the better the reimbursement. Knowing the rules also will reduce, or eliminate, the chance of audits uncovering hospital errors.

About the Author

Janis Oppelt is editorial director for MedLearn Publishing, a Panacea Healthcare Solutions, Inc. company, St. Paul, MN.

Contact the Author


To comment on this article please go to editor@racmonitor.com

Risky Business: Outpatient Therapy


Janis Oppelt

Janis Oppelt was the former editorial director for MedLearn Publishing.

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