Malnutrition Diagnosis and Coding

• Supporting consistent documentation across the malnutrition care pathway, including screening, assessment, diagnosis, treatment and monitoring.
• Developing a nationally consistent approach to documenting malnutrition diagnosis and severity following comprehensive assessment using validated tools.
• Contributing to a standardised national approach to malnutrition coding.
• Aligning clinical documentation with ICD coding requirements.
• Working with the Quality, Data and Outcomes workstream to support auditing, and national reporting.
• Participating in a Delphi consensus process to refine and finalise nationally agreed assessment and diagnostic recommendations.
• Engaging with stakeholders to ensure recommendations are practical, evidence-based and nationally applicable.

If adopted and implemented, the workstream's recommendations are intended to:

• Support consistent diagnosis and documentation of malnutrition severity across all healthcare settings.
• Improve the accuracy and consistency of malnutrition coding.
• Enable reliable national reporting and meaningful comparisons of malnutrition data across Aotearoa New Zealand.
• Support quality improvement, research, policy development, service planning and resource allocation through better data.
• Improve continuity of nutrition care across services and settings.
• Contribute to equitable and culturally safe malnutrition care for Māori, Pacific peoples and all New Zealanders.

• Reviewing current malnutrition diagnosis, documentation and coding practices across health services.
• Developing a nationally consistent approach to documenting malnutrition diagnosis in the clinical record following comprehensive assessment using validated tools.
• Supporting consistent use of NCPT diagnosis terminology using the Problem, Etiology Signs and Symptoms format.
• Defining the clinical evidence required to support documentation of malnutrition and its severity.
• Monitoring and reviewing the development and validation of emerging diagnostic frameworks and criteria (e.g. GLIM) for suitability in the New Zealand context.
• Aligning clinical documentation with national ICD coding standards and requirements.
• Supporting the integration of screening, assessment and treatment documentation within the malnutrition care pathway.
• Working with the Quality Data and Outcomes workstream to support auditing and reporting.

Recommendation 1: Standardise documentation of malnutrition screening, assessment, and diagnosis

Dietitians should document their comprehensive nutrition assessment & reassessment findings including the validated nutrition assessment tool that was used and relevant findings related to client history, anthropometry, biochemical data, physical exam findings and the food and nutrition related history.

Dietitians should document the malnutrition diagnosis and supporting evidence using consistent Nutrition Care Process Terminology, and a Problem, Etiology, Signs and Symptoms (PES) statement.

Documentation should include:

• A diagnosis that includes the word malnutrition (note 1)
• The severity of malnutrition (mild, moderate or severe)
• The etiology or contributing factors
• The signs and symptoms providing the clinical evidence for the diagnosis.

Supporting evidence should be drawn from comprehensive assessment findings, such as SGA, Scored PG-SGA, the full MNA.

Dietitians should document the treatment goal and the nutrition intervention/ care plan developed to that address the malnutrition diagnosis.

Applicable settings: Acute inpatient, rehabilitation, aged residential care, community, outpatient, primary care and private healthcare settings. Future recommendations will refer to these collectively as all health care settings.

Note 1:

In the New Zealand acute care environment clinical coding practice uses ICD-10-AM/ACHI version 12 which is governed by the application of the following: Australian Coding Standards (ACS); IHACPA Coding Rules; New Zealand clinical coding conventions; and National Minimum Dataset (NMDS) reporting requirements.

Following these standards, rules and reporting requirements promotes clinical coding consistency. This results in the recording of quality National Minimum Dataset data that are comparable at a national and international level.

The Nutrition Care Process Terminology (NCPT) includes a range of nutrition diagnoses that may be associated with malnutrition, such as undernutrition, unintentional weight loss, and inadequate oral intake. However, these terms are not equivalent to a documented malnutrition diagnosis and do not independently support assignment of an ICD-10-AM malnutrition code.

NCPT malnutrition diagnoses and corresponding ICD-10-AM malnutrition codes

• Severe malnutrition — E43 Unspecified severe protein-energy malnutrition
• Moderate malnutrition — E44.0 Protein-energy malnutrition of moderate degree
• Mild malnutrition — E44.1 Mild protein-energy malnutrition
• Malnutrition, severity not specified — E46 Unspecified protein-energy malnutrition (used only when severity cannot be specified)

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Recommendation 2: Documentation of malnutrition onset

Where relevant, dietitians should document whether malnutrition was present or suspected on admission or developed during the episode of care. This information can support clinical coding, quality improvement activities, outcome monitoring, and benchmarking.

Setting: Recommended for all but will only be coded for in acute settings or other healthcare settings using ICD-10-AM /ACHI criteria.

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Recommendation 3: Improve malnutrition documentation across the continuum of care

Dietitians should document monitoring and evaluation findings that indicate changes in nutrition status and the malnutrition diagnosis (e.g. active or resolved) and revise the nutrition care plan where required.

Malnutrition diagnosis and its current status, along with the nutrition care plan, should be included in the discharge summaries and transfer of care documentation.

Setting: All health care settings. Note in some settings dietitians will need to request access to be able to document in discharge summaries or transfer of care documentation.

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Recommendation 4: Support digital interoperability, outcome reporting and benchmarking

Future digital health systems should support the recording of malnutrition information as structured data that align with current ICD classification and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT), rather than relying on free-text clinical documentation.

Suggested information could include, but not limited to:

• The validated screening tool used, its score and the action taken
• The validated assessment tool used and its outcome
• The NCPT malnutrition diagnosis statements (including severity) and diagnosis tracking (e.g. resolved, ongoing).
• The diagnostic framework used if applicable
• Treatment goals, interventions, and monitoring and evaluation findings

Structured data elements embedded into the electronic health record will support the following:

• ICD-10-AM coding (acute care)
• SNOMED CT where implemented, including relevant concepts from the SNOMED CT-NCPT Reference Set
• Electronic health record reporting
• Quality improvement activities
• National reporting
• Benchmarking
• Research and prevalence monitoring

The MCANZ workstreams are guided by a Steering Group, which provides strategic oversight and helps ensure the work reflects clinical, community and health system needs across Aotearoa New Zealand.

Workstream Co-Chairs

• Kristy Pemberton, NZRD, MSc
• Amy Flett, NZRD, MDiet

Members

• Jessie Casas, NZRD, MND
• Emma Cummack, NZRD, MDiet