Exploring Malnutrition Coding

It’s never too early to think about compliance issues as they relate to coding, no matter whether you’ve just started learning about coding or have many years of experience. This is particularly true when coding issues are found to profoundly affect reimbursement. One issue that continues to make coding compliance headlines involves the diagnosis of malnutrition.

Two hospital systems have had millions of dollars in fines levied against them due to the malnutrition issue. Code 260, Kwashiorkor, is most at issue. The code carries a “major complication/comorbidity” (MCC) designation, meaning that on hospital claims it can translate to thousands of inappropriate dollars in reimbursement from Medicare and other payers who use the DRG inpatient prospective payment system (IPPS).

But kwashiorkor is defined as an extremely severe wasting disease of malnutrition that occurs in children after weaning as a result of severe protein deficiency. The word is Ghanan, meaning “the displaced child’s visible condition” and is usually in a child weaned from breast feeding when the mother has another child.

So why would a disease that most commonly affects children in third-world countries be found in some high-income areas of California or Maryland? Nutritional experts don’t typically think of kwashiorkor in terms of adult patients, and many have never seen a case of it in the United States. Generally, kwashiorkor occurs when drought, famine or societal unrest leads to an inadequate food supply. Protein-depleted diets in such areas are mostly based on starches and vegetables, with little meat and animal products.

A contributing factor to inappropriate code assignment may be due to an over-reliance on the ICD-9-CM diagnosis index without taking into account information in the tabular list or information in the Coding Clinic for ICD-9-CM. If a diagnosis of “protein malnutrition” is found in a medical record with no further information, the coder may use the following indexed entry from the ICD-9-CM alphabetic index:

Malnutrition (calorie) 263.9

protein 260

At first glance it may appear that code 260 is appropriate for “protein malnutrition” but there is further information in the tabular list. While the indexed entry above does not mention kwashiorkor, the code title indicates the condition, and the inclusion term states “Nutritional edema with dyspigmentation of skin and hair,” obviously representing a severe condition. A sticking point appeared to be the term “protein” when documented with malnutrition. Some coding professionals did not realize they could assign a code from category 263, Other and unspecified protein-calorie malnutrition, for protein malnutrition. The Coding Clinic for ICD-9-CM clarified the issue in the 3rd quarter 2009 edition, page 6:

“Assign only code 263.0, Malnutrition of moderate degree, for moderate protein malnutrition. This code category includes protein-calorie malnutrition. Code 260, Kwashiorkor, is not appropriate because the provider did not specifically document this condition. Kwashiorkor syndrome is a condition that is caused by severe protein deficiency that is usually seen in some underdeveloped areas in Africa and Central America; however it is extremely rare in the United States.”

Effective Oct. 1, 2010, new entries were added to the alphabetic index of ICD-9-CM as well, providing the modifying term “(protein)” to subentries for “mild” and “moderate” malnutrition. In this way, it will be easier for coding professionals to understand that mild and moderate protein malnutrition should be coded with the appropriate code from category 263, and not with code 260.

The other issue that may be driving some inappropriate kwashiorkor code assignment is related to an inappropriate practice of using lab values alone to diagnose the condition. Overzealous efforts to “improve” physician documentation to optimize reimbursement may involve querying the physician and asking him or her to add “protein malnutrition” based on lab values. This is particularly an issue when it may include adding a complication/comorbidity (CC) condition that may increase reimbursement. This is also clearly against official coding guidelines for reporting secondary conditions, which indicate that the additional diagnoses should only be assigned when the condition affects patient care in terms of requiring:

  • Clinical evaluation; or
  • Therapeutic treatment; or
  • Diagnostic procedures; or
  • Extended length of hospital stay; or
  • Increased nursing care and/or monitoring.

While physician querying is a necessary process in hospitals today, querying only for those conditions that will yield a code that is designated as a CC or MCC is suspect, especially if only based on lab values.

The differences in reimbursement can be significant. For example, if a Medicare patient is admitted for treatment of a stroke (cerebral infarction) and there are no complicating diagnoses on the case, the typical reimbursement is approximately $4,200. But when the kwashiorkor (a major complication/comorbidity) code is added to the case, reimbursement increases to approximately $9,600, a $5,400 increase!

Coding management staff at acute care facilities should closely monitor their data related to malnutrition to ensure the cases are coded appropriately and only when the physician has clearly documented the condition. Codes may not be assigned based solely on a dietician’s assessment. In addition, inpatient coding professionals should ensure the codes designated as CCs or MCCs are only assigned when at least one of the requirements for coding secondary conditions listed above is present and clearly documented. Further, any staff members involved in clinical documentation improvement (CDI) programs should be counseled on the appropriate assignment of these codes and when it would be acceptable to issue physician queries for them. Both CDI and coding staff members have been trained to assign the highest severity codes in order for the facility to obtain the reimbursement to which it’s entitled. However, these codes must be assigned legitimately and not merely based on a few words or lab values in the medical record documentation or on one interpretation of the ICD-9-CM alphabetic index.

Test your knowledge with the following questions:

1. If the medical record documentation includes “mild protein malnutrition” the code assignment would be:

a. 263.1

b. 263.9

c. 260

d. 261

When documentation only includes the word “malnutrition,” the coder should:

a. Assign code 263.9

b. Query the physician for additional clarification concerning the type and severity of malnutrition

c. Refer to the dietician’s notes for clarification

d. Refer to the lab values for severity

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, hospital solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.

Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.


1. a. The alphabetic index indicates that mild (protein) malnutrition should be assigned to code 263.1.

2. b. Although code 263.9 could be assigned if no further information is found, the coder should query the physician to ensure that the most appropriate code is selected. Codes should not be assigned based solely on dietician notes and lab values.

About The Author