Q&A: Documentation and ICD-10-CM coding for severe malnutrition

July 26, 2019

Medicare Web

Q: What clinical information can be used to support the reported diagnosis of severe malnutrition and how would this be coded in ICD-10-CM?

A: To meet the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for severe malnutrition in an acute care setting, a patient must present with the following symptoms:

Energy intake: <50% estimates energy requirement for >5 days
Weight loss (% of body weight):
- >2% in one week; or
- >5% in one month; or
- >7.5% in three months
Muscle mass loss: moderate
Body fat loss: moderate
Edema masking weight loss: moderate to severe
Reduced grip strength: measurably reduced

Coders would use ICD-10-CM code E43 to report severe malnutrition, also known as starvation edema. They would use ICD-10-CM code E42 to report severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus.

While most healthcare facilities still follow the ASPEN criteria, in 2018, the American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Clinical Nutrition and Metabolism, the Latin American Nutritional Federation, and the Parenteral and Enteral Nutrition Society of Asia published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community,” in the Journal of Parenteral and Enteral Nutrition.

The GLIM malnutrition criteria are outlined below.

Phenotypic criteria
Weight loss % (unintended)	5% < 6 months, or 10% > 6 months
Low body mass index (BMI)	< 20 if < 70 years, or < 22 if > 70 years
Reduced muscle mass	Reduced by objective measures and/or physical exam
Etiologic criteria
Reduced nutritional intake	< 50% of requirement > 1 week, or any reduction > 2 weeks, or chronic GI disorders with adverse nutrition impact
Inflammation	Chronic disease, or acute disease/injury with severe systemic inflammation, or socio-economic/environmental starvation

Under the new criteria, severity of malnutrition is based on phenotypic criteria only, and requires one phenotypic criterion that meets these thresholds:

Moderate (stage 1) malnutrition		Severe (stage 2) malnutrition
Weight loss % (unintended)	5%–10% < 6 months, or 10%–20% > 6 months	> 10% < 6 months, or > 20% > 6 months
Low BMI	< 20 if < 70 years, or < 22 if > 70 years	< 18.5 if < 70 years, or < 20 if > 70 years
Reduced muscle mass	Mild-to-moderate deficit (per validated assessment methods*)	Severe deficit (per validated assessment methods*)

From a coding perspective, GLIM identifies only moderate and severe malnutrition. Malnutrition stage is not an indexed term, so if Stage 1 is documented, code E46 (unspecified malnutrition) may be used. If only Stage 2 is documented, it must be clarified as severe for correct coding of the condition.

At this time, the ASPEN criteria are still being followed in the U.S. However, the standard clinical criteria for diagnosing severe malnutrition are actively evolving.

Editor’s note: This question was answered by Richard Pinson, MD, FACP, CCS, during the HCPro webinar, “GLIM: New Global Malnutrition Definition and Its Impact on Coding and CDI.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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