Q&A: Documenting malnutrition as a secondary diagnosis

August 17, 2020
Medicare Web

Q: What documentation elements are required to support a secondary diagnosis of malnutrition? Can the diagnosis be made based on lab results?

A: The documentation should present a clinical sense that the patient is experiencing a nutritional disturbance. Based on the documentation, it must first be determined that the malnutrition/severe malnutrition meets the ICD-10-CM’s definition of a secondary diagnosis (did it require an evaluation, treatment, increased nursing care, and/or length of stay?). After determining that severe malnutrition meets the secondary diagnosis requirements, attention must be directed to the clinical documentation itself. The diagnosis cannot be made based solely on laboratory results. The medical record should include both physician documentation and a registered dietician’s nutrition assessment as it relates to the patient’s degree of malnutrition. Documentation may indicate a need for nutrition, but nutritional need should not be abstracted as malnutrition/severe malnutrition. Supporting documentation should include the following if applicable to the patient scenario:

  1. Type of malnutrition (e.g., severe protein calorie malnutrition or nutritional marasmus, which is attributed to both protein and caloric intake malnutrition).
  2. Verification of two of the six ASPEN characteristics in the documentation. If the patient has experienced weight, muscle, and body mass loss as well as reduced grip strength, those variables should be properly documented.
  3. Notation of other conditions associated with or contributing to the severe malnutrition.


For more information, see "Note from the instructor: Severe malnutrition is under OIG scrutiny again," by Yvette M. DeVay, MHA, CPC, CPMA, CIC.