HealthCare News

Malnutrition Coding Guidelines

Issue: #402 JUL2018

Topic: Coding/Billing

Blue Cross Blue Shield of ND (BCBSND) has recently submitted the Malnutrition Coding Guideline to an outside consultant to determine the validity of the guideline for continuation of use. Following review, it has been determined the BCBSND Malnutrition Coding Guidelines will remain in use as originally published by BCBSND. These coding guidelines should be referenced by inpatient coders at facilities when assigning codes for malnutrition on BCBSND member inpatient claims.

General Guidelines

Documentation within the medical record should support the presence of any coded condition. In addition, the condition should require utilization of resources during the current episode of care to receive reimbursement. Conditions not requiring treatment, or that have been treated and reimbursed prior to admission, are carefully monitored to ensure the integrity of the DRG database and payment system.

Official guidelines from the Uniform Hospital Discharge Data Set (UHDDS), which define when a diagnosis can be coded, state that a diagnosis should be coded if documented by the physician in the patient’s medical record for the current admission and the condition was:

  • Clinically evaluated during the patient’s stay; or
  • Therapeutically treated during the stay; or
  • Diagnostically tested during the stay; or
  • Caused an increased length of stay; or
  • Required increased nursing monitoring and care.

The condition meets criteria for newborn diagnosis coding if any of these guidelines are met or the physician’s documentation indicates a need for future follow-up or health care needs.

Classification of Malnutrition

BCBSND has adopted the World Health Organization (WHO) Classification of malnutrition in adults by body mass index (BMI). This information can be found at:

Classification of malnutrition in adults by body mass index

Body mass indexNutritional status
≥ 18.5Normal
17.0-18.49Mild malnutrition
16.0-16.99Moderate malnutrition
<16.0Severe malnutrition

The attending provider is responsible for listing the diagnoses in the patient record and must document malnutrition to justify reporting a code for the body mass index.

In addition to the patient’s current BMI, the following criteria should be documented when assigning a code for malnutrition:

  • A comprehensive dietary history
  • The determining factors considered in making a diagnosis of malnutrition
    • Laboratory testing alone is an unreliable means to confirm the presence of malnutrition.
    • Abnormal levels of serum protein (albumin, transferrin and pre-albumin) are more likely to reflect the degree of illness in a hospitalized patient rather than the presence of malnutrition.
  • Signs and symptoms commonly associated with malnutrition
  • Specific interventions required to manage malnutrition (e.g. TPN, enteral feedings). These interventions should be an integral component of the patient’s case management. Dietary consults and oral nutritional supplements in the form of vitamins or protein supplements such as Boost or Ensure do not constitute additional resource utilization.

BCBSND reserves the right to review clinical documentation to ensure the condition meets both UHDDS and BCBSND guidelines for reporting malnutrition.