Gastroenterology Coding Alert

Use the GLIM criteria to help you recognize requirements.

An unsupported malnutrition diagnosis is a common reason for a denial, according to Nancy Reading RN, BS, CPC, CPC-P, CPC-I, DRG auditor for CERIS in Goose Creek, South Carolina, in her 2024 HEALTHCON session “Making a Diagnosis of Malnutrition Stick.” The documentation requirements are specific, and the criteria have evolved over the last few years.

Gastroenterology coders need to be sure they understand how to provide payers with the proper information to support a malnutrition diagnosis and the treatment. Keep reading to see what our expert has to say about proper documentation.

Review GLIM: The Gold Standard for Malnutrition Support

In 2016, a group of international clinical nutrition societies established the Global Leadership Initiative on Malnutrition (GLIM) for the purpose of developing global consensus criteria for the clinical diagnosis of malnutrition in adults. These parameters take the place of the American Society of Parenteral and Enteral Nutrition (ASPEN) criteria.

The GLIM criteria include two steps: screening and assessment.

Screening: Clinicians identify high-risk individuals using validated screening tools.

Assessment: Clinicians can confirm the malnutrition diagnosis based on the presence of at least one etiologic and one phenotypic criterion.

These criteria provides a standardized and globally accepted method for diagnosing malnutrition. However, the documentation required to support the diagnosis is not as widely understood.

Understand Screenings and Required Documentation

The screening phase requires the use of a validated screening tool to identify patients who are at high risk for malnutrition. Such tools are:

• Nutritional Risk Screening 2002 (NRS 2002)
• Mini Nutritional Assessment Short Form (MNA SF)
• Malnutrition Universal Screening Tool (MUST)

Without record of the physician using these tools to identify risk, which could be could be low, moderate, or high, payers are going to deny the claim. The documentation also needs to include the physician’s conclusion.

Remember the Assessment Details

According to the GLIM criteria, a malnutrition diagnosis requires the presence of at least one phenotypic factor and one etiologic factor.

Phenotypic factors: These factors essentially ask the question, has the patient’s “appearance changed as a result of prolonged weight loss or prolonged inability to assimilate nutrients?” said Reading. Repeated and recorded weight measurement over an identified period of time is required to identify weight losses or gains. Basically, this comes down to three potential clinical observations:

• Degree of weight loss
• Body Mass Index (BMI)
• Loss of muscle mass

Look for these measurements: Physicians identify reduced muscle mass using body composition measuring techniques such as dual-energy absorptiometry or bioelectrical impedance, ultrasound, computed tomography or magnetic resonance imaging (MRI). A physical exam or anthropometric measures of calf or arm muscle circumference might also be in the patient record. According to Reading, a nutrition-focused specific exam includes an evaluation of muscle mass, fat stores, edema, functional capacity (grip strength), orbital fat loss (sunken eyes), and buccal fat loss (cheek bones). Additionally, the physician will likely look at the triceps, ribs, forehead and clavicle for signs of fat and/or muscle loss.

Etiologic factors: These factors essentially ask the question, “what are the deficiencies secondary to: insufficient intake, chronic disease, increased nutrient needs, weight loss surgery, etc,” Reading explained. Pay attention to these measurable signs:

• Deficit in intake
• Malabsorption or digestive issues
• Underlying diseases or conditions causing inflammation

Look for these measurements: Physicians will measure deficit in intake by calculating the percentage of energy requirements the patient can take in per meal or day. “Remember that the inability to take in food and nutrients can occur in cases of nausea secondary to chemo, or esophageal ulcers or tumors,” said Reading. Also, look for notes indicating the patient has experienced less than or equal to 50 percent of energy requirements for more than one week or reduction for greater than two weeks. The physician may also mark down chronic GI conditions that adversely impact food assimilation or absorption.

Note: “Inflammation is a new parameter that GLIM has recently linked to malnutrition, and this is seen in acute disease or injury, or it can be related to chronic diseases such as cancer and renal failure,” explained Reading.

Stages: “Categorization of the severity of malnutrition is dependent on the degree of deviation from the established criteria,” Reading explained. Here are the stages, followed by a description of how to support each stage:

• Stage 1 (moderate): Show weight loss of 5-10 percent within the past six months or 10-20 percent weight loss for greater than six months or BMI of less than 20 if the patient is under 70 years old or BMI less than 22 if the patient is over the age of 70 years old or approved measurement techniques showing mild to moderate loss of muscle mass.
• Stage 2 (severe): Show weight loss of greater than 10 percent within the past six months or greater than 20 percent weight loss for greater than 6 months or BMI of less than 18.5 if the patient is under 70 years old or BMI less than 20 if the patient is over 70 years old or approved measurement techniques showing severe loss of muscle mass.

Caution: Overweight, obesity, and diet-related noncommunicable diseases can also cause malnutrition. If the patient is obese, that limits the number of observational signs of malnutrition, which forces you to rely on other measurements to support the diagnosis.

Recognize These Common Documentation Deficits

These are common documentation hiccups, followed by ways to avoid them.

Cloned exam notes: “What’s the first thing under ‘Constitutional’ that most notes say? Well developed, well nourished. If we have that in the exam, and then you have a diagnosis of severe protein calorie malnutrition, what am I supposed to do with that?” asked Reading.

Try building a provider template to pull into the record to help draw attention to the actual findings.

Treating provider neglects the assessment: Diagnosing malnutrition is the first part of supporting a diagnosis, but treatment must also be documented to lend support to the presence and severity.

You never want to clone notes, however, if the diagnosis was made by another specialist; the gastroenterologist can pull the assessment and make notes indicating agreement. That can successfully support the diagnoses.

Lack of information about underlying reason for malnutrition: Incomplete documentation is often the result of a physician in a hurry.

Query your provider. If the necessary testing and measurement details aren’t available, you can hopefully use that opportunity to help the provider understand the importance of marrying the documentation with supportive clinical findings for next time.

Look to these Malnutrition ICD-10 Codes

Malnutrition diagnoses will fall between E40 (Kwashiorkor) and E46 (Unspecified protein-calorie malnutrition). This family of codes has the following excludes notes:

• Excludes1: intestinal malabsorption (K90.-), and sequelae of protein-calorie malnutrition (E64.0)
• Excludes2: nutritional anemias (D50-D53), and starvation (T73.0)

You’ll report the diagnosis using one of the following malnutrition diagnosis codes:

• E40
• E41 (Nutritional marasmus)
• E42 (Marasmic kwashiorkor)
• E43 (Unspecified severe protein-calorie malnutrition)
• E44.- (Protein-calorie malnutrition of moderate and mild degree)
  o E44.0 (Moderate protein-calorie malnutrition)
  o E44.1 (Mild protein-calorie malnutrition)
• E45 (Retarded development following protein-calorie malnutrition)
• E46

Documentation alert: Reporting E44.1 requires the clinical record meet the basic malnutrition criteria and reporting E44.0 requires the clinical record to meet both the basic malnutrition and the moderate malnutrition criteria to pass a clinical audit.

Note: E44.0, E44.1, E44.3, and E46 are also considered comorbid conditions, so the claim may require multiple ICD-10 codes.