Ensuring Compliant Malnutrition
By Gloryanne Bryant, RHIA, CCS, CCDS
CCODING MALNU TRITION HAS always been a challenge, espe- cially since MS-DRGs were implemented. However, with Recov- ery Audit Contractors and other regulatory auditing being initi- ated across the country, providers and HIM professionals must be proactive rather than reactive when coding this condition. This article shares new concerns regarding malnutrition doc- umentation and coding practices and highlights steps for im- proving coding compliance. Malnutrition Defined There are many published definitions for malnutrition. The New York Times’ health guide defines malnutrition as the condition that occurs when a person’s body is not getting enough nutrients. The condition may result from an inadequate or unbalanced diet, digestive difficulties, absorption problems, or other
medical conditions. 1
Malnutrition may be mild enough to show no symptoms.
However, in some cases it may be so severe that the damage
done is irreversible, even though the individual survives.
Worldwide, malnutrition continues to be a significant problem, especially among children who cannot fend adequately
for themselves. Often malnutrition is seen in patients with liver
disease, hepatitis, chronic and systemic diagnoses, and in alcoholics.
Coding and Reimbursement for Malnutrition
ICD-9-CM separates malnutrition into several codes to capture
the degree and specific type of malnutrition. The ICD-9-CM
Index of Diseases includes a list of malnutrition subcategories;
however, coding professionals know not to code from the alpha
index alone. It is necessary to consult the tabular listing and the
“includes” and “excludes” instructional notes.
ICD-9-CM code 260, Kwashiorkor, represents a syndrome
that includes nutritional edema with dyspigmentation of skin
and hair. It affects children and involves excessive carbohydrate
with inadequate protein intake, inhibited growth potential,
anomalies in skin and hair pigmentation, edema, and liver disease. Kwashiorkor often is seen in third-world countries.
According to The Merck Manuals, kwashiorkor is derived from
an African term that means “first-second child.” This is because
it usually affects children who are weaned due to the birth of a
second child. 2
In some inpatient cases a diagnosis of “protein malnutrition”
may be documented, which would be assigned to code 260,
Kwashiorkor. But did the physician really intend for the diagnosis of kwashiorkor to be reported?
Under the Inpatient Prospective Payment System MS-DRGs,
ICD-9-CM code 260 is a major complication/comorbidity, or
MCC. In some cases, ICD-9-CM code 260 may be the only MCC,
which groups to a higher relative weight MS-DRG. The diagnosis “protein malnutrition” indexes to 260, Kwashiorkor, while
“protein-caloric malnutrition” indexes to ICD-9-CM code 263.9
(which is a CC).
For example, a 65-year-old female is discharged from a hospital in May 2011 with a principal diagnosis of acute kidney injury
(ICD-9-CM code 584.9) and a secondary diagnosis of protein
malnutrition (ICD-9-CM code 260). This results in assignment
of MS-DRG 682 Renal Failure with MCC, with a relative weight