Malnutrition Diagnosis and Documentation Flashcards
6 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Malnutrition Diagnosis and Documentation flashcards as text
Which ASPEN/AND malnutrition criterion is BEST assessed by handgrip dynamometry?
Answer: Diminished functional status
Handgrip strength measured by dynamometry is an objective assessment of functional status, one of the six ASPEN/AND malnutrition criteria. Reduced handgrip strength is associated with malnutrition-related muscle weakness.
A patient with severe heart failure has significant peripheral edema and ascites. How does this affect malnutrition assessment and documentation?
Answer: Fluid retention overestimates body weight, potentially masking weight loss from malnutrition
In patients with significant edema or ascites, body weight is overestimated because fluid accumulation masks actual lean tissue loss.
A critically ill ICU patient on total parenteral nutrition (TPN) still meets ASPEN criteria for severe malnutrition based on inadequate pre-admission intake and significant muscle wasting. Can malnutrition be coded?
Answer: Yes; malnutrition coding is based on clinical presentation, not current nutritional support
Malnutrition can be documented and coded based on the clinical presentation and criteria present at or during the admission, regardless of whether the patient is currently receiving nutritional support.
Which ICD-10-CM code is used when a physician documents 'cachexia' without specifying an underlying cause?
Answer: R64 - Cachexia
R64 is the ICD-10-CM code for cachexia when no underlying cause is specified. Cachexia is a complex metabolic syndrome associated with underlying illness such as cancer, heart failure, COPD, or renal failure.
A CDI specialist is reviewing a bariatric surgery patient who presents 18 months post-operatively with documented inadequate protein intake and muscle wasting. What type of malnutrition is MOST likely?
Answer: Non-illness-related malnutrition due to inadequate intake; document ASPEN criteria met
Post-bariatric malnutrition due to restricted intake and malabsorption is classified as non-illness-related malnutrition. Documentation should include ASPEN criteria including inadequate protein and energy intake plus evidence of weight loss, muscle wasting, or other criteria met.
Which approach BEST reflects a comprehensive hospital malnutrition documentation improvement program?
Answer: Implementing a multidisciplinary team approach with dietitians screening, CDI querying, and physicians documenting
A comprehensive malnutrition documentation program requires a multidisciplinary approach: dietitians use validated screening tools and ASPEN criteria to identify at-risk patients, CDI specialists use dietitian assessments as triggers to query physicians, and physicians document the confirmed diagnosis.