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    Malnutrition Table

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    Teddy Kurniady Thaher
    This document discusses the importance of documenting a patient's body mass index (BMI) and any associated abnormal conditions in the medical record. It provides BMI criteria and classifications for conditions like morbid obesity, obesity, overweight, and underweight. The diagnosis of malnutrition is complicated and depends on factors like physical findings, risk factors, biochemical markers, weight loss, and the physician's clinical judgment. Proper documentation of abnormal BMI and associated conditions can affect quality performance scores and reimbursement.

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    Malnutrition Table

    Uploaded by

    Teddy Kurniady Thaher
    193 views1 page
    This document discusses the importance of documenting a patient's body mass index (BMI) and any associated abnormal conditions in the medical record. It provides BMI criteria and classifications for conditions like morbid obesity, obesity, overweight, and underweight. The diagnosis of malnutrition is complicated and depends on factors like physical findings, risk factors, biochemical markers, weight loss, and the physician's clinical judgment. Proper documentation of abnormal BMI and associated conditions can affect quality performance scores and reimbursement.

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    This document discusses the importance of documenting a patient's body mass index (BMI) and any associated abnormal conditions in the medical record. It provides BMI criteria and classifications for conditions like morbid obesity, obesity, overweight, and underweight. The diagnosis of malnutrition is complicated and depends on factors like physical findings, risk factors, biochemical markers, weight loss, and the physician's clinical judgment. Proper documentation of abnormal BMI and associated conditions can affect quality performance scores and reimbursement.

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    © All Rights Reserved
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    193 views1 page

    Malnutrition Table

    Uploaded by

    Teddy Kurniady Thaher
    This document discusses the importance of documenting a patient's body mass index (BMI) and any associated abnormal conditions in the medical record. It provides BMI criteria and classifications for conditions like morbid obesity, obesity, overweight, and underweight. The diagnosis of malnutrition is complicated and depends on factors like physical findings, risk factors, biochemical markers, weight loss, and the physician's clinical judgment. Proper documentation of abnormal BMI and associated conditions can affect quality performance scores and reimbursement.

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    of 1

    acp-hosp1104_acp-hosp0000 3/23/11 4:01 PM Page 8

    CODING CORNER

    WEIGHING

    IN ON

    BMI

    By Richard D. Pinson, FACP

    patients body mass index (BMI) can have a profound effect


    on the complexity of care and the risks of complications,
    morbidity and mortality. In addition, BMI <19 or BMI 40 is
    classified as a comorbidity that can affect quality performance
    scores and reimbursement.
    To qualify, the abnormal BMI must be documented specifically in the medical record by the physician or by a nutritionist. There must also be a clinical diagnosis or condition documented by the physician that corresponds to the abnormal
    BMI. Incorporating the BMI with vital signs on the history
    and physical (especially for electronic records) helps to meet
    this requirement.
    A BMI 40 with the terms morbid obesity, obesity or
    overweight would qualify as a diagnosis. For BMI <19, a diagnosis of underweight, nutritional risk or malnutrition will
    do, particularly if a nutrition consult is requested.

    BMI criteria
    BMI (kg/m2)

    Associated condition

    40

    Morbid obesity

    30-40

    Obesity

    25-30

    Overweight

    19-25

    Normal

    <19

    Underweight

    The diagnosis of malnutrition is classified independently as


    a co-morbidity. If documented as severe, malnutrition contributes to an even higher complexity of care and severity of illness. However, the diagnosis of malnutrition is complicated and
    multi-factorial, and includes:
    Physical findings like emaciation or muscle wasting (e.g.
    temporal wasting, thenar atrophy).
    Risk factors such as cancer, chemotherapy, AIDS, alcoholism, end-stage disease processes, malabsorption syndromes,
    or other gastrointestinal and pancreatic disorders.
    Biochemical markers including low albumin, prealbumin, cholesterol, transferrin, BUN/creatinine ratio, and/or
    anemia.
    Recent or progressive weight loss; low body weight.
    The ultimate diagnosis of malnutrition and its severity
    depends upon the physicians clinical judgment based on a

    8 ACPHOSPITALIST April 2011

    SEND US YOUR CODING QUESTIONS


    Got a documentation or coding conundrum? Let ACP
    Hospitalist help you. Dr. Pinson will respond to selected
    questions from readers in this Coding Corner column. Email your question to [email protected] and
    receive a quick answer, then see it published in an upcoming issue. Anonymous queries are acceptable.

    constellation of the above findings in each individual case.


    No particular finding is required or definitive. Its interesting
    to note that coding rules consider emaciation to be severe
    malnutrition but not cachexia, even though most physicians use the terms interchangeably.

    General classification of malnutrition*


    Criteria

    Severe

    Moderate

    Mild

    Albumin (g/dL)

    2.0

    2.5

    3.0

    Prealbumin (mg/dL)

    <5.0

    <10.0

    <15.0

    Ideal body weight

    <70%

    <80%

    <90%

    Usual body weight

    <75% or

    <85%

    <95%

    10% loss <6 mo


    BMI (kg/m )
    2

    <16

    <17

    <18.5

    *The diagnosis of malnutrition is multi-factorial and based on


    clinical judgment. No particular finding is required or definitive.

    In summary, it is very important to have abnormal BMI


    documented in the medical record as well as the clinical condition associated with it. The diagnosis of malnutrition and its
    severity is also important but requires consideration of multiple
    clinical variables. g
    Richard Pinson, FACP, is a certified coding specialist and co-founder
    of HCQ Consulting (www.hcqconsulting.com) in Houston. This content is adapted with permission from HCQ Consulting.

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