Identifying Malnutrition in the Adult Patient
It Makes “Cents”
Maria Browning, MS, RDN, CNSC
3/14/2016
1
Objectives/Outline
• What is Malnutrition: breaking down the
consensus statement
• Where does malnutrition fit: Value Based
Purchasing, CMS and coding
• How does malnutrition make cents
• Next steps
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2
Malnutrition
WHERE WE HAVE BEEN AND
WHERE WE ARE NOW
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3
Defining Malnutrition
• Simply put malnutrition begins when food and nutrient intake are
consistently inadequate
• Inadequate intake results in changes in weight, body
composition, and physical function
• Malnutrition in hospitalized or chronically ill patients is often a
combination of cachexia (disease related) and malnutrition
(inadequate consumption of nutrients) as apposed to malnutrition
alone
Baker, et al., 2011
Consequences of Malnutrition
• Multicenter retrospective analysis showed pt’s with
pre-existing malnutrition had increased risk of C-diff,
surgical site infection, postoperative pneumonia, >5
fold higher risk of mediastinitis, and catheter
associated UTI
• Immune suppression, delayed wound healing,
pressure ulcer formation, functional losses leading to
increased fall risk
• Longer hospital stays
Baker, et al., 2011
Malnutrition: Where we have been
• Historically based on the serum proteins
albumin and prealbumin
• Merck Manual guidelines followed by CMS
• Should malnutrition be a “never” event in
hospitals?
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6
Merck Manual Table
Values Commonly Used to Grade the Severity of Protein-Energy Undernutrition
Measurement
Normal
Mild
Undernutrition
Moderate
Undernutrition
Severe
Undernutrition
Normal weight
(%)
90–110
85–90
75–85
< 75
Body mass
index (BMI)
19–24*
18–18.9
16–17.9
< 16
Serum albumin
3.5–5.0
(g/dL)
3.1–3.4
2.4–3.0
< 2.4
Serum
transferrin
(mg/dL)
220–400
201–219
150–200
< 150
Total
lymphocyte
count (per µL)
2000–3500
1501–1999
800–1500
< 800
2
1
0
Delayed
hypersensitivity 2
index†
*In the elderly, BMI < 21 may increase mortality risk.
†Delayed
hypersensitivity index uses a common antigen (eg, one derived from
Candida sp or Trichophyton sp) to quantitate the amount of induration elicited by skin
testing. Induration is graded: 0 =< 0.5 cm, 1 = 0.5–0.9 cm, 2 =≥ 1.0 cm.
http://www.merckmanuals.com/professional/nutritional-disorders/undernutrition/protein-energy-undernutrition
7
Malnutrition: Where we are now
• Malnutrition Consensus statement of 2012
• Etiology based malnutrition diagnosis
• 6 independent criteria used to support
malnutrition in the acute, chronic and social
etiologies of malnutrition
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The Consensus Statement
• Purpose is to define malnutrition for adults in all settings
• Current approaches to diagnosis malnutrition vary widely and
lack evidence
• A.N.D and A.S.P.E.N recommend a standardized set of
diagnostic characteristics to be use to identify and document
adult malnutrition
White, et al., 2012
Etiology-Based Malnutrition Definitions
Characteristics of Malnutrition
• 1) Insufficient food and nutrient intake
• 2) Weight loss over time
• 3) Loss of muscle mass
• 4) Loss of fat mass
• 5) Fluid accumulation
• 6) Diminished functional status
White, et al., 2012
Energy Intake and Weight Loss
• Review diet history
• Assess current intake
• Trend measured
weights
• Compare actual intake • Determine percent of
weight loss over time
vs. requirements
• Consideration of fluid
balance alterations
• Body composition
changes might mask
weight loss
White, et al., 2012
Physical Assessment
• Muscle mass evaluation
– Temporalis, Pectoralis, Deltoids, Trapezius,
Interosseous, Quadriceps
• Body fat evaluation
– Temple, chest/ribs, arms, legs
Malone, 2012
Fluid Accumulation
• On physical exam assess for edema
– Generalized or localized fluid
accumulation
• Edema can mask actual weight loss
White, et al., 2012
Edema: Etiology
• Generalized Edema:
– Heart Failure
– Cirrhosis
– Nephrotic Syndrome
– Massive Fluid Resuscitation in Trauma Patients
• Clinically Evident on Exam
• Pitting
• Non-pitting
Functionality
• Hand Grip Strength
–A diminished hand grip shows functional decline and is
related to malnutrition
–Currently it’s the only validated tool used to document
function decline
• Other Functional Makers
–Assess overall energy, strength, and endurance
–Examples: ability to perform ADL’s, wean from
mechanical ventilator
White, et al., 2012
Malnourished?
• Each of the characteristics used to
diagnosis malnutrition may be seen in
patients who malnutrition is not the
appropriate diagnosis
White, et al., 2012
Pay for performance, the reward and penalty of:
VALUE BASED PURCHASING
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18
Evolution of Value Based
Purchasing
FY 2013
(1% base Op DRG
payment at risk)
Patient Experience of Care
(8 dimensions)
30%
FY 2014
FY 2015
FY 2016
FY 2017
(1.25% base Op DRG (1.5% base Op DRG (1.75% base Op DRG (2.00% base Op DRG
payment at risk)
payment at risk)
payment at risk)
payment at risk)
Patient Experience of Care
(8 dimensions)
30%
Patient Experience of Care
(8 dimensions)
30%
Patient Experience of Care
(8 dimensions)
25%
Clinical Process of Care measures
Clinical Process of Care measures
(8 measures) 10%
(13 measures)
20%
Clinical Process of Care
(12 measures)
70%
Clinical Proces of Care
(13 measures)
45%
Outcome Domain
(3 measures)
25%
Outcome Domain
(75measures)
30%
Efficiency Domain
(1 measure)
20%
Outcome Domain
(7 measures)
30%
Efficiency Domain
(1 measure)
25%
Patient Experience of Care
(8 dimensions)
25%
Clinical Care-Processmeasures
(3 measure) 5%
Outcome Domain
(7 measures)
30%
Safety Domain
(6 measures)
20%
Efficiency Domain
(1 measure)
25%
*
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Performance Impact on FY 2016 &
FY 2017
VALUE BASED PURCHASING PROGRAM
FY 2016 (Current cycle)
CY 2013
CY 2014
CY 2015
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
CALENDAR YEAR
Clinical Process of Care Domain
Patient Experience of Care Domain
Efficiency Domain
Outcomes Domain: CLABSI, CAUTI
Outcomes Domain- Mortality: AMI, HF, PN
Maximum $ at Risk
(3,550,089)
Affects Medicare
Reimbursement from
Oct 1, 2015 to Sept 30,
2016
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Outcomes Domain- PSI 90 Composite
VALUE BASED PURCHASING PROGRAM
FY 2017 (Next cycle)
IMPACT
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Max At Risk
$(3,394,259) Oct 2016
CLABSI, CaUTI, SSI Colon, Hysterectomy
*
IMPACT
Max At Risk
$(6.146,725) Oct 2016
PSI 90 Composite
FEDERAL FISCAL YEAR
IMPACT
Max At Risk
$(6.085,866)-Oct 2015
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
HOSPITAL ACUIRED CONDITIONS REDUCTION
PROGRAM:FY 2016
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Outcomes Domain- PSI 90 Composite
HOSPITAL READMISSIONS REDUCTION
PROGRAM : FY 2017
AMI, COPD, HF, PN, THA/TKA, CABG
IMPACT
Maximum $ at Risk
(4,097,816)
Affects Medicare
Reimbursement from
Oct 1, 2016 to Sept
30, 2017
We
a re
here
Clinical Care: Process & Outcome Domains
Patient Experience of Care Domain
Efficiency Domain
Outcomes Domain: CLABSI, CAUTI
Outcomes Domain- Mortality: AMI, HF, PN
HOSPITAL READMISSIONS REDUCTION
PROGRAM : FY 2016
AMI, COPD, HF, PN, THA/TKA
IMPACT
FY 2013
FY 2014
FY 2015
20
Value Based Purchasing FY2017
• Outcomes (3 measures)
– AMI 30 day Mortality
– HF 30 day Mortality
– PN 30 day Mortality
Value Based Purchasing FY2017
• Safety (7 measures)
– Catheter associated urinary tract infection
– Central line associated blood stream infection
– Surgical site infection (colon, hysterectomy)
– MRSA (methicillin resistant staph aureus)
– C. difficile
– Patient Safety Indicator PSI-90
PSI-90 Components
• PSI 06 Iatrogenic Pneumothorax Rate
• PSI 07 Central Venous Catheter-Related Blood Stream
Infection Rate
• PSI 08 Postoperative Hip Fracture Rate
• PSI 09 Perioperative Hemorrhage or Hematoma Rate
• PSI 10 Postoperative Physiologic and Metabolic
Derangement Rate
• PSI 11 Postoperative Respiratory Failure Rate
• PSI 12 Perioperative Pulmonary Embolism or Deep Vein
Thrombosis Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound Dehiscence Rate
• PSI 15 Accidental Puncture or Laceration Rate
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Hospital Readmission Reduction
Program FY2017
• All cause readmission
– AMI
– HF
– PN
– COPD
– Elective Hip Arthroplasty
– Elective Knee Arthroplasty
– Coronary Art Bypass Graft
• Up to 3% penalty!
*
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CMS 2015 Measure Updates:
MALNUTRITION VARIABLES
FOR AMI, HF, PNEUMONIA,
COPD AND STROKE
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CMS 2015 Measure Updates
• 2015 Condition-Specific Measures Updates and
Specifications Report
– Hospital-Level 30-Day Risk-Standardized
Mortality Measures
– Hospital-Level 30-Day Risk Standardized
Readmission Measures
• Charts from report are simplified to show top 5
results and nutrition related risk factors.
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Odds Ratio
• An odds ratio (OR) is a measure of association
between an exposure and an outcome1.
• The OR represents the odds that an outcome will
occur given a particular exposure, compared to
the odds of the outcome occurring in the absence
of that exposure1.
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Odds Ratio
OR=1
OR>1
OR<1
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Exposure does not affect the
odds of the outcome
Exposure associated with
higher odds of outcome
Exposure associated with
lower odds of outcome
28
Mortality and AMI
Table 4.2.3 – Adjusted OR for the AMI Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Anterior myocardial infarction (ICD-9 codes 410.00-410.12)
Metastatic cancer, acute leukemia and other severe cancers (CC 7-8)
Other location of myocardial infarction (ICD-9 codes 410.20410.62)
Protein-calorie malnutrition (CC 21)
Pneumonia (CC 111-113)
2.23
2.02
1.67
1.66
1.54
Other Nutrition Related Results:
14
Diabetes mellitus (DM) or DM complications except proliferative
retinopathy (CC 15-20, 120)
1.1
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
mortality following AMI by 1.66.
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Mortality and HF
Table 4.3.3 – Adjusted OR for the HF Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Protein-calorie malnutrition (CC 21)
Metastatic cancer, acute leukemia and other severe cancers (CC 7-8)
Chronic liver disease (CC 25-27)
Dementia or other specified brain disorders (CC 49-50)
Pneumonia (CC 111-113)
1.96
1.81
1.55
1.37
1.32
Other Nutrition Related Results:
18
Diabetes mellitus (DM) or DM complications except proliferative
retinopathy (CC 15-20, 120)
0.98
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30day
mortality in HF patients by 1.96.
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Mortality and Pneumonia
Table 4.4.3 – Adjusted OR for the Pneumonia Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer, acute leukemia, and other severe cancers (CC 7-8)
Protein-calorie malnutrition (CC 21)
Dementia or other specified brain disorders (CC 49-50)
Chronic liver disease (CC 25-27)
Cardio-respiratory failure or shock (CC 79)
3.17
2.18
1.49
1.4
1.26
Other Nutrition Related Results:
11 Iron deficiency or other unspecified anemias and blood disease (CC 47)
1.18
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
mortality in Pneumonia by 2.18.
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Mortality and COPD
Table 4.5.3 – Adjusted OR for the COPD Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer or acute leukemia (CC 7)
Protein-calorie malnutrition (CC 21)
Lung, upper digestive tract, and other severe cancers (CC 8)
Cardio-respiratory failure or shock (CC 79)
Decubitus ulcer or chronic skin ulcer (CC 148149)
2.37
2.12
1.83
1.45
1.35
Other Nutrition Related Results:
8
Iron deficiency or other unspecified anemias and blood disease (CC 47) 1.28
24 Diabetes mellitus (DM) or DM complications (CC 15-20, 119-120)
0.96
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
mortality in COPD by 2.12.
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Mortality and Stroke
Table 4.6.3 – Adjusted OR for the Stroke Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer, acute leukemia and other severe cancers (CC 7-8)
Protein-calorie malnutrition (CC 21)
Specified arrhythmias (CC 92)
Quadriplegia, other extensive paralysis (CC 67-69)
Pneumonia (CC 111-113)
2.64
1.73
1.58
1.49
1.47
Other Nutrition Related Results:
12 Iron deficiency or other unspecified anemias and blood disease (CC 47)
1.2
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
mortality after Stroke by 1.73.
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Readmission and AMI
Table 4.2.3 – Adjusted OR for the AMI Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer, acute leukemia and other severe cancers (CC 7-8)
Protein-calorie malnutrition (CC 21)
Specified arrhythmias (CC 92)
Quadriplegia, other extensive paralysis (CC 67-69)
Pneumonia (CC 111-113)
2.64
1.73
1.58
1.49
1.47
Other Nutrition Related Results:
12 Iron deficiency or other unspecified anemias and blood disease (CC 47)
1.2
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
readmission due to AMI by 1.73.
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Readmission and HF
Table 4.3.3 – Adjusted OR for the HF Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Renal failure (CC 131)
Severe hematological disorders (CC 44)
Metastatic cancer or acute leukemia (CC 7)
Chronic obstructive pulmonary disease (COPD) (CC 108)
Congestive heart failure (CC 80)
1.19
1.18
1.16
1.16
1.14
Other Nutrition Related Results:
6
Iron deficiency or other unspecified anemias and blood disease (CC 47)
15 Diabetes mellitus (DM) or DM complications (CC 15-20, 119-120)
16 Protein-calorie malnutrition (CC 21)
1.14
1.08
1.08
Example: A diagnosis of Iron deficiency anemia increases the risk of 30 day
readmission due to HF by 1.14.
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Readmission and Pneumonia
Table 4.4.3 – Adjusted OR for the Pneumonia Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer or acute leukemia (CC 7)
Severe hematological disorders (CC 44)
Chronic obstructive pulmonary disease (COPD) (CC 108)
Iron deficiency or other unspecified anemias and blood disease (CC 47)
Lung, upper digestive tract, and other severe cancers (CC 8)
1.25
1.23
1.2
1.19
1.18
Other Nutrition Related Results:
8
Disorders of fluid/electrolyte/acid-base (CC 22-23)
1.14
10 Protein-calorie malnutrition (CC 21)
1.13
16 Diabetes mellitus (DM) or DM complications (CC 15-19, 119-120)
1.08
Example: A diagnosis of Iron deficiency anemia increases the risk of 30 day
readmission due to Pneumonia by 1.19.
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Readmission and COPD
Table 4.5.3 – Adjusted OR for the COPD Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer or acute leukemia (CC 7)
Cardio-respiratory failure or shock (CC 79)
Lung, upper digestive tract, and other severe cancers (CC 8)
Congestive heart failure (CC 80)
Severe hematological disorders (CC 44)
1.24
1.22
1.22
1.21
1.19
Other Nutrition Related Results:
8
Disorders of fluid/electrolyte/acid-base (CC 22-23)
1.16
11 Protein-calorie malnutrition (CC 21)
1.15
30 Diabetes mellitus (DM) or DM complications (CC 15-20, 119-120)
1.05
Example: A diagnosis of disorders of fluid/electrolyte/acid-balance increases the risk of
readmission due to COPD by 1.16.
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Readmission and Stroke
Table 4.6.3 – Adjusted OR for the Stroke Hierarchical Logistic
Regression Model from 07/2011-06/2014
Top Results:
1
2
3
4
5
Metastatic cancer or acute leukemia (CC 7)
End-stage renal disease or dialysis (CC 129-130)
Protein-calorie malnutrition (CC 21)
Iron deficiency or other unspecified anemias and blood disease (CC 47)
Severe hematological disorders (CC 44)
1.43
1.35
1.33
1.22
1.2
Other Nutrition Related Results:
8
Diabetes mellitus (DM) or DM complications (CC 15-20, 119-120)
12 Disorders of fluid/electrolyte/acid-base (CC 22-23)
1.15
1.12
Example: A diagnosis of Protein-calorie malnutrition increases the risk of 30 day
readmission due to Stroke by 1.33.
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Coding and Clinical Documentation
WHAT IS THE VALUE?
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Performance Index Severity Adjusted Data
= 1; as good as the next guy
- 
Observed mortality
Expected mortality
from severity adjusted DRGs
<1; preferred provider –
significantly better

>1; excessive mortality; find
another provider - 
Observed Rate of Some Thing
Severity Adjusted Expected Rate of That Thing
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=1
40
CDIP Metrics
• A quality Clinical Documentation Improvement Program will
influence the following metrics:
 Severity of Illness (SOI) & Risk of Mortality (ROM) – these
metrics range from level 1 (minor) to level 4 (extreme)
• SOI – looks at the co-morbid illnesses of the patients
• ROM – the mortality likelihood based on the present diseases
 Mortality Index – ratio of the actual mortality/ the expected
mortality. The lower the metric the better performer. If this
metric is over 1, then it perceives that the facility is providing a
substandard quality of care.
• Accurate and complete physician documentation will allow for
precise coding and assignment of the SOI and ROM levels which
will result in representing the true acuity of the patient
population. The SOI and ROM are utilized in calculating the
facilities Mortality Index which is widely used for quality
outcomes benchmarking.
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Documentation Supported
Higher Level of Acuity
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SOI
ROM
MI
(Severity of Illness)
(Risk of Mortality)
(Mortality Index)
4
4
3
2
1
Documentation Supported
Higher Risk of Mortality
3
1.0
2
Better Performer
Higher Quality of Care
CDIP Metrics, cont…
1
42
Is There a Diagnosis?
82 yo WF shaking chills, fevers, altered
mental status, decr UO, T = 103, P = 124,
R = 34, BP = 70/40 persistent despite 1 L
NS, on Dobutrex, pO2 = 78 on nonrebreather, pH = 7.18, pCO2 = 105, WBC =
17,500, left shift, BUN = 78, Cr = 5.4, CXR
– RUL infiltrate, start Cefipime, Clinda, Tx
to ICU. May have to intubate – full resusc.
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Which better reflects SOI?
Assessment/Plan
82 YO F patient presented to ER with
Fever of unknown origin, shaking chills,
hypotension,
azotemia,
elevated Creatinine,
respiratory insufficiency, and
respiratory acidosis
Will transfer to ICU, continue
Dopamine and monitor respiratory
status for possible worsening of her
hypoxemia/insufficiency and
initiate Cefipime, Clinda for
pulmonary infiltrates.
CC time 1hr 45 minutes
John Smith MD
3/14/2016
Assessment/Plan
82 YO F patient presented to ER with
1. Septic Shock,
2. Acute Respiratory Failure,
3. Acute Renal Failure,
4. Probable Aspiration pneumonia
Will transfer to ICU, continue Dopamine
and monitor respiratory status for
possible worsening of her Ac Resp
Failure and initiate
Cefapime/clindamycin for possible
…… aspiration pneumonia
(?organism, etiology)
CC time 1hr 45 minutes
John Smith MD
44
So What’s the Difference?
Principal Diagnosis
Chills and Fever
Hypotension
Respiratory acidosis
Renal insufficiency
Altered mental status
Lung infiltrates
Severe Sepsis
Septic Shock
Acute Respiratory Failure
Acute Renal Failure (AKI)
Metabolic Encephalopathy
Aspiration Pneumonia
Medicare MS-DRG
864 Fever w/o CC/MCC
871 Septicemia or severe Sepsis
w/o MV 96+ hrs w/ MCC
APR-DRG
722 Fever
720 Septicemia & Disseminated
infection
Secondary Diagnoses
APR-DRG Severity of Illness 1 – Minor
4 – Extreme
APR-DRG Risk of Mortality
1 – Minor
4 – Extreme
Medicare MS-DRG Rel Wt
0.8153
1.8437
APR DRG Relative Weight
0.3556
2.9772
National Mortality Rate
(APR Adjusted)
0.04%
62.02%
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Case Example
• Assessment/Plan
Assessment/Plan
79 YO F pt presented to ER w/
Decompensated Systolic HF,
AFib,
CAD,
DM,
Malnutrition – Alb 1.9
BMI under 19
• 79 YO F pt presented to ER w/
–
–
–
–
–
Decompensated Systolic HF
AFib,
CAD,
DM,
Malnutrition - Unspecified
• LOS = 3 days
LOS = 3 days
Medicare MS-DRG
292 – Heart Failure & Shock
w/CC
291 – Heart Failure & Shock w/ MCC
Severity of Illness
2 – Moderate
3 – Major
Risk of Mortality
2 – Moderate
3 – Major
Average LOS
3.1 days
5.9 days
Medicare MS-DRG
Relative Weight
0.9938
1.5031
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46
3/14/2016
Putting it all together
WHAT MAKES “CENTS”
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47
Malnutrition and the Big Picture
• Aligned with hospital score card to meet quality
standards
• Significant variable in risk adjust mortality and
to some extent readmission risk
• Malnutrition contributes to actual coding a
reimbursement
• Potential prevention of never events like
wounds that are not reimbursable
• Prevention of other infections (CAUTI, C-diff)
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The Cost of Malnutrition
August 2015 Data from and MH
Malnutrition
Patients
VDC
Cost per patient
No malnutrition
Totals
151
559
710
2,864,136
5,104,785
7,968,921
$18,968
$9,132
$11,224
2Xs the COST!
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Future Directions
• Collect data to better understand acuity
variables
• Uses current data to advocate for nutrition and
dietitians in the hospital
• Create better processes to ensure adequate
nutrition
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50
Special Thanks
• Ann Cotton, Emily Myatt, Allison Sattison,
Audrey Dubord, Lena Wilson and Carla
Zacchondi
• IAND
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51
Thank You!
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52