DRG 640 Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC, 641 without MCC

Malnutrition (E41 and E43)
Under the inpatient prospective payment system, the Centers for Medicare & Medicaid Services (CMS) pays inpatient hospital costs at predetermined rates for patient discharges. The rates vary according to the diagnosis-related group (DRG) to which a patient’s stay is assigned and the severity level of the patient’s diagnosis. The DRG payment is, with certain exceptions, intended to be payment in full to the hospital for all inpatient costs associated with the patient’s stay. The DRG and severity level are determined according to diagnosis codes established by the ICD-10-CM. 

Nutritional marasmus (diagnosis code E41) and unspecified severe protein-calorie malnutrition (diagnosis code E43) are two types of severe malnutrition. Previous OIG audits of severe malnutrition found that hospitals had incorrectly billed Medicare by using severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all. Diagnosis codes E41 and E43 (severe malnutrition diagnosis codes) are each classified as a type of major complication or comorbidity (MCC).

What clinical information can be used to support the reported diagnosis of severe malnutrition?
To meet the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for severe malnutrition in an acute care setting, a patient must present with the following symptoms:

• Energy intake: less than (<) 50 percent estimates energy requirement for greater than (>) 5 days
• Weight loss (percent of body weight):
  • >2 percent in one week; or
  • >5 percent in one month; or 
  • >7.5 percent in three months
• Muscle mass loss: moderate
• Body fat loss: moderate
• Edema masking weight loss: moderate to severe
• Reduced grip strength: measurably reduced

Documentation to include (this list is not all inclusive) :

• Physician admission order and note 
• History and physical
• Emergency department documentation (if applicable)
• Progress notes (nursing, therapy, dietary)
• Discharge summary supporting the identification, diagnosis, and treatment plans for the diagnosis of severe protein-calorie malnutrition
• Physician documentation of physical appearance
• History of nutritional intake
• Weight history to support severe protein-calorie malnutrition
• Labs
• Dietitian/nutrition assessments

Medication Administration Record (MAR) and Treatment Administration Record (TAR) Resources

• ICD-10-CM/PCS MS-DRG v37.0 Definitions Manual
• Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims, A 03 17-00010 (PDF)
• ASPEN | Clinical Guidelines 
• Q&A: Documentation and ICD-10-CM coding for severe malnutrition | ACDIS
• FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule — CMS-1771-F | CMS