Query for Severe Protein Calorie Malnutrition

Good Morning.

I have a 95 y/o patient who was admitted with CVA.  She meets ASPEN criteria for severe protein calorie malnutrition.  Her family wanted only comfort care and was transferred to hospice care the day after admission.

Dietary did do a nutritional assessment, but there was no other treatment or follow up regarding her malnutrition.  I am not certain whether to attempt a post-discharge query to get this diagnosis on the chart.  I know it will increase her SOI/ROM but it was not really addressed during her stay.

Thoughts?  Thank, you!



  • A bit controversial.  Q:  Is the fact she has Severe PCM a contributing risk factor in regards to mortality? 

    "Must" a condition be treated in order to be coded per the UHDDS Guidelines? (No - see the Guidelines for reporting requirements). 

    Did the RN staff modify any activities and document any modalities in the Nursing Care Plan that would acknowledge the condition and be addressed by the RN staff?

    A common misconception (and sometimes invalid reason) for denying the reporting of certain conditions is the thought that 'it was not treated, so it Can't be Coded".  This is not valid per the Guidelines.

     Think about the patient admitted with severe ICH causing hernia of the brain.  He is evaluated, and the staff note that due to the Hernia and vasogenic edma, he should be placed on Comfort Care.  No pressure checks, no medications, and no therapy directed towards reversal of the edema and hernia.  The manifestations of the ICH, the edema/hernia, are cited as irreversible by Neurology, and are factors for the decision to place on Comfort Care.  As such, both are reportable.

    Can we make a similar argument for severe PCM that is not actively managed, but is present?

    A condition  meets the criteria for a secondary diagnosis if the physician documents the condition, evaluates the condition, or monitors the condition in some fashion that meets the criteria set forth in such that the condition qualifies in terms of any of the following:


    • Clinical Evaluation

    • Therapeutic Treatment

    • Further evaluation by diagnostic studies, procedures or consultation

    • Extended LOS

    • Increased nursing care and/or other monitoring

    Per Faye Brown’s ICD-9-CM Coding Handbook, 2004 edition, “Clinical evaluation means that the physician is aware of the problem and is evaluating it in terms of testing, consultations, and close clinical evaluation of the patient’s condition.  Note that a physical examination alone does not qualify as further evaluation or clinical evaluation; the physical examination is a routine part of every hospital admission.”


    Question:  A patient was admitted with diet controlled Type II DM.  The presence of DM was clearly documented in the H&P.  The attending ordered daily blood sugars, and nursing staff checked blood sugars before each meal.  The patient was continued on his diabetic diet.   No active treatment for the DM was given to this patient.  Is the Type II Diabetes Mellitus reportable?

    Paul Evans, RHIA

  • Thanks Paul, that all makes sense. She would have been monitored if her LOS was longer, but she was inpatient for only over night.  From what you are saying, it sounds like Clinical Evaluation is the golden nugget.  The dietician did an excellent evaluation complete with documentation of ASPEN criteria.


  • Thank you - as I stated, complicated and controversial.  My main point is that many 3rd parties will deny if not actively treated:  Just as they deny morbid obesity now, even though that condition clearly is reportable.  I am just stating that we need to think a bit more critically on such issues.  I fully expect most 3rd parties WILL deny severe PCM if not 'actively managed', and I maintain they are incorrect on that basis, alone, and without some consideration as to the true purpose of reporting valid risk factors that, when present, impact morbidity and mortality.


  • edited December 2018
    I agree with Paul, as always! And besides, you "evaluated." Didn't you expend resources to have a dietary consult? It is medically relevant that the patient has malnutrition. It should be coded and captured.
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