Key coding considerations for malnutrition

A review across settings and countries in Europe, the United States, and South Africa found the prevalence of malnutrition among 4,507 older adults (mean age 82.3, 75.2% female) was 22.8%. According to research on older adults with acute hospitalization, up to 71% are at nutritional risk or are malnourished. The elderly are at greater risk due to increased comorbidities; related organ system compromise; and the reduced ability to access, prepare, and ingest food.

Documentation of underweight or abnormal weight loss will not impact DRG [diagnosis-related group] assignment as a comorbidity, but these diagnoses do impact hospital quality metrics and rankings.

Abnormal weight loss, cachexia, and protein-calorie malnutrition are equally weighted and significantly impact publicly reported hospital rankings and PSI [patient safety indicator] metrics. Underweight is not included. Documentation should demonstrate reportability as a significant diagnosis.

Cachexia provides a CC [complication or comorbidity] as a secondary diagnosis and will continue to impact CMS-HCC [hierarchical condition category] risk adjustment until version 28 is fully phased in in 2026. Documentation should identify the underlying chronic illness and disease processes contributing to the compromised state.

Codes E40, E41, and E42 (kwashiorkor, nutritional marasmus, and marasmic kwashiorkor, respectively) rarely should be seen in the United States. The presence of these codes on a claim likely will trigger an audit; if they are used, the documentation should demonstrate clear support of their presence.

Coders should be alert to all comorbidities often accompanying malnutrition, including the presence of chronic illness, malignancies, depression, non-healing wounds, prolonged ventilation time, functional quadriplegia, or substance abuse/dependence.

Malnutrition may be overlooked in the obese population because weight loss may not be as apparent and/or may be assumed to be intentional when it wasn’t so. The physician must still apply diagnostic criteria to the patient. A statement of weight loss from the physician is not enough; specification of how much weight loss over what period of time is needed. Physicians should also document whether the weight loss was intentional.

Vitamin deficiencies are very common after a gastric bypass, especially if the patient does not take all of the vitamin and mineral supplements as ordered. Documentation of noncompliance is needed as well as the specific deficiencies. The documentation should identify the deficits related to micronutrients (Vitamins B1, B6, and B12; folic acid; vitamins C, A, D, and E; zinc; chromium; and selenium).

Documentation should indicate the primary source of calories as well as an education plan related to diet choices.

Social determinants of health influence a patient’s health status and should be considered in both assessment and treatment plans. Review records with consideration of challenges such as housing insecurity, food insecurity, low income, and material hardship.

Editor’s note: This article is an excerpt from the “2025 JustCoding Pocket Guide” by Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS.