CCDS Malnutrition Diagnosis and Documentation 2

Question 1

According to ASPEN/AND diagnostic criteria, which finding is required to diagnose malnutrition in any clinical setting?

Accepted Answer

Inadequate energy intake as a mandatory criterion

Answer

The ASPEN/AND 2012 consensus statement requires inadequate energy intake as a mandatory criterion for malnutrition diagnosis in all contexts, combined with at least one additional criterion.

Question 2

A patient is admitted with a chronic illness and is found to have moderate malnutrition. In ICD-10-CM, which code range best captures moderate protein-energy malnutrition?

Accepted Answer

E44 - Protein-energy malnutrition of moderate and mild degree

Answer

E44 covers protein-energy malnutrition of moderate (E44.0) and mild (E44.1) degree. E41 is reserved for severe marasmus-type malnutrition.

Question 3

Why are serum albumin and pre-albumin NO LONGER recommended as primary markers for malnutrition diagnosis?

Accepted Answer

They are negative acute phase reactants that decrease during inflammation regardless of nutritional status

Answer

Albumin and pre-albumin are negative acute phase reactants and their levels decrease during inflammation or illness regardless of a patient's actual nutritional intake.

Question 4

A registered dietitian documents 'moderate malnutrition' in a nutrition consult note. What additional step is REQUIRED before this diagnosis can be coded?

Accepted Answer

The attending physician must document or confirm the malnutrition diagnosis in the medical record

Answer

Dietitian documentation of malnutrition provides the clinical basis for a CDI query but does not alone support coding. The attending physician must document or confirm malnutrition as a diagnosis in the medical record.

Question 5

Which malnutrition severity level has an MCC designation that directly affects DRG assignment?

Accepted Answer

Severe malnutrition (E41, E43)

Answer

Severe protein-energy malnutrition codes E41 (Nutritional marasmus) and E43 (Unspecified severe protein-energy malnutrition) are designated as MCCs in the MS-DRG system. Moderate malnutrition (E44.0) is a CC.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Malnutrition Diagnosis and Documentation 2