From the Clinical Documentation Team

  • Please specify degree of Malnutrition (mild, moderate, severe) whenever possible. Not ideal for coded chart to have unspecified malnutrition.
  • Nutritionists use the American Society for Parental and Enteral Nutrition (ASPEN) criteria to determine degree of malnutrition.
  • CDI use nutrition consults as the main support when posting queries for malnutrition. CDI will all also use BMI, lab values, wt changes.
  • If you agree with a malnutrition diagnosis, please support this in your progress notes by reinforcing what the nutrition consult states and the treatment. (However, be aware of conflicting information in your physical assessment. If you document malnutrition but the physical assessment says, “well-developed and well-nourished,” it will be at risk for denial.)
  • Reminder: Cachexia is a separate Vizient variable, so it’s important to document if present.

REMEMBER: Always answer CDI queries (They are here to help you!). Any questions for the clinical documentation team please call Jean Banzhof, 717-544-4426.

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