By Jennifer Doley, Regional Clinical Nutrition Manager and Dietetic Internship Director, Morrison Healthcare
Morrison is on a mission to raise awareness about malnutrition. I’m doing my part, as a registered dietitian, by encouraging other RDNs to become more vigilant in notifying doctors and documenting our findings when we diagnose a patient as malnourished. Doing so is critical not just for patient care but it also makes a big difference for hospitals who receive financial resources in proportion to documented cases of malnutrition.
I recently examined an elderly man suffering from severe malnutrition. He didn’t eat much and his significant muscle and fat loss was clear. He lived alone and didn’t have the resources needed to obtain and prepare food at home, so he ate once a day in a restaurant; often it was his only meal for the day. These are the kinds of severely malnourished patients that have a high risk for complications and need the help of the RDN to treat their malnutrition.
To document my concerns, I recently did an extensive data review on malnutrition and coding practices at a local hospital. The goal was to determine how many patients who – despite being classified as malnourished – were not coded for malnutrition. The data showed that the RDNs identified 1,817 malnourished patients between March 2015 and June 2017. Of these, 1,171 (64.4%) were not coded for malnutrition.
Of those 1,171 patients who were not coded for malnutrition, nearly 41 percent of them would have improved reimbursement for the hospital for Medicare patients covered by the Center for Medicare and Medicaid Services (CMS) if they had been coded for malnutrition. Greater reimbursement can mean more resources to care for these patients. If under coding is happening at one hospital, it’s likely happening at hospitals across the country.
The data from my study revealed that malnourished patients stayed an average of 5.3 days in the hospital. For those that were not coded for malnutrition as they should have been, their expected length of stay was 3.5 days. Proper coding would have more accurately reflected the severity of their condition.
The issue seems simple: if a person is suffering from malnutrition, doctors should document it as such. So why isn’t this happening? Lack of education is the primary cause.
To be sure that patients are properly coded, first the RDN needs to diagnose malnutrition. There are recommended guidelines that should be used to determine if a patient is malnourished. RDNs should be comfortable with these guidelines and understand how to conduct a physical exam to identify signs of malnutrition. RDNs should document their findings, including the results of a physical exam, to make it easy for the doctor to immediately find this information.
Doctors also need to diagnose and document malnutrition. For many doctors, malnutrition is not a top priority. This however, makes sense – doctors’ primary focus is on the cause of patient sickness – determining why the patient is in the hospital.
Regardless, physicians need to be educated on current guidelines for diagnosing malnutrition. Reason being, even though RDNs perform a complete physical exam, physicians often conduct their own. The issue however, is that many physicians often rely on albumin, a protein found in blood to measure malnutrition.
However, this particular measure is no longer part of the guidelines used to diagnose malnutrition. Albumin increases as inflammation subsides, regardless of how much protein is consumed. Because of its relationship to inflammation, albumin is no longer considered a good indicator of malnutrition. Yet, because this is the measure that was taught many years ago, many older doctors still rely on it.
So what happened at the hospital where I performed the study? Afterwards, I spent some time presenting and educating the physicians at the hospital on properly diagnosing malnutrition. I’m so pleased to say we’ve seen significant improvements in their use of the appropriate guidelines! This means accurate coding is happening more frequently, and a hospital that used to miss out on reimbursements, is now able to benefit from them.
While this is exciting, further education and improved communication with RDNs everywhere is needed. Many physicians still do not properly code for malnutrition on many malnourished patients, but from my experience, with an increased focus on education we can change that trend. As malnutrition and proper coding becomes prominent on more physicians’ radar, levels of reimbursement, and thus improved resources, will increase.
These findings highlight an opportunity to improve upon claims submitted to the Center for Medicare and Medicaid Services. With this knowledge, claims can better reflect the acuity level of patients served and amount of care provided. It’s a win for our patients, and a win for our clients.
You can read my latest research on this topic, published in the Journal of the Academy of Nutrition and Dietetics.