FREE CCDS Malnutrition Diagnosis and Documentation Questions and Answers

Question 1

According to the ASPEN/AND consensus criteria, a diagnosis of malnutrition in an adult patient requires the presence of at least how many clinical characteristics?

Accepted Answer

Two

Answer

One

Answer

Three

Answer

Four

Question 2

A 75-year-old patient has a documented energy intake of 65% of estimated needs for over a month, a 7% weight loss in 6 months, and mild muscle wasting. Which is the most appropriate severity of malnutrition for a CDS to query the provider for?

Accepted Answer

Moderate malnutrition

Answer

Severe malnutrition

Answer

Mild (Non-severe) malnutrition

Answer

No malnutrition is present

Question 3

A provider documents 'poor nutritional status' and 'low albumin' in the record for a cachectic patient. Why is this documentation insufficient for accurate coding?

Accepted Answer

It lacks a specific, codeable diagnosis and the clinical criteria to support it.

Answer

It does not specify the patient's BMI.

Answer

Low albumin is not related to nutrition.

Answer

The term 'cachectic' is sufficient for coding.

Question 4

What is the key factor that differentiates the etiology of 'chronic disease-related malnutrition' from 'starvation-related malnutrition'?

Accepted Answer

The presence of a mild to moderate inflammatory response

Answer

The speed of weight loss

Answer

The patient's age

Answer

The level of serum prealbumin

Question 5

A patient with congestive heart failure has significant peripheral edema and a stable weight, but also has visible temporal wasting and poor grip strength. How should the CDS proceed?

Accepted Answer

Query the provider to assess for malnutrition based on muscle loss and functional status.

Answer

Conclude that malnutrition cannot be diagnosed due to the stable weight.

Answer

Focus only on the congestive heart failure diagnosis.

Answer

Recommend a nutrition consult without querying for a diagnosis.

Question 6

Which of the following documentation examples provides the highest level of specificity for coding and MS-DRG impact?

Accepted Answer

Severe protein-calorie malnutrition

Answer

Malnutrition

Answer

Nutritional deficiency

Answer

Failure to thrive