营养不良诊断、记录、编码的现行做法和存在问题：营养实践学组营养支持营养师调查

　　营养不良患者医疗费用报销要求对营养不良进行恰当的诊断、记录及编码。

　　为此，美国营养与饮食学会（A.N.D.）营养实践学组、托马斯杰斐逊大学医院、拉什大学医学中心、克利夫兰医学中心、美史达华盛顿医院中心对美国2718位注册营养师进行问卷调查，其中652位完成调查。

　　调查结果显示74%的营养师诊断标准选择ASPEN标准，而小医院或非学术性医疗机构的营养师选择ASPEN标准的比例较低；在学术性医疗机构工作的营养师具有更高的营养不良诊断率（87%比76%，P=0.001）；营养师对营养不良诊断率随其工作单位规模的增大而增加（＜200床：77%，201～500床：81%，＞500床：88%，P=0.04）。

　　此外，大型或学术型医疗机构对营养不良的记录及编码做得较好。

JPEN J Parenter Enteral Nutr. 2017;41(2):297.

Current practices and perceived barriers to diagnosing, documenting, and coding for malnutrition: a survey of Dietitians in Nutrition Support Dietetic Practice Group.

Stephanie D. Dobak; Sarah Peterson; Mandy L. Corrigan; Jennifer Lefton.

Dietitians in Nutrition Support, Chicago, Illinois, USA; Nutrition & Dietetics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; Food and Nutrition, Rush University Medical Center, Chicago, Illinois, USA; Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA; MedStar Washington Hospital Center, Washington, DC, USA.

Purpose: Malnutrition is prevalent among hospitalized patients, and these patients require more resources and care. Proper identification, documentation, and coding of malnutrition are needed for institutional reimbursement. We sought to determine registered dietitians’ (RD/RDNs) current practices in diagnosing, documenting, and coding for malnutrition within their institutions.

Methods: A questionnaire was created to determine RD/RDN current practices and perceived barriers to diagnosing, documenting, and coding malnutrition within their institutions. An online, self-serve, survey platform (SurveyMonkey) was used to distribute survey questions to RD/RDN members of the Dietitians in Nutrition Support (DNS) practice group (n = 2718 members) within the Academy of Nutrition and Dietetics (Academy). An institutional review board approved the study protocol, and participants provided electronic informed consent. Count (percentage) was used to summarize RD/RDN practice characteristics and survey responses. A χ² analysis was used to explore the associations between RD/RDN practice characteristics with malnutrition documentation and coding practices.

Results: In total, 652 DNS members completed the survey (24% response rate). The majority of RD/RDNs cover adult patients (66% adult, 25% combination of adult/pediatric). RD/RDN practice characteristics varied by years of experience and healthcare setting; 20% are entry level (<3 years), 21% have worked for 4-9 years, 13% have worked both 11-15 and 16-24 years, and 33% have worked >25 years. Half of the sample works in an academic healthcare setting (46%), while the remainder practices in nonacademic hospitals (43%) or other facilities (12%). Size of healthcare facilities differed among respondents; 25%, 42%, 15%, and 8% work in facilities with <200, 201-500, 501-800, and >800 beds, respectively. The majority (79%) of RD/RDNs diagnose malnutrition; 74% use the Academy/American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to identify malnourished patients. Prevalence of RD/RDN diagnosing malnutrition was significantly different by practice characteristics. RD/RDNs working in academic settings are more likely to diagnose malnutrition compared with those in the nonacademic setting (87% vs 76%, P = .001). Similarly, likelihood of RD/RDN diagnosing malnutrition increases as hospital beds increase (<200:77% vs 201-500:81% vs >500:88%, P = .04). RD/RDN diagnosing malnutrition was not different by years of experience. Survey responses indicated that the majority of primary care providers (PCPs) at their institutions are documenting (89%) and diagnosing (89%) malnutrition; however, only 28% of those providers are using the Academy/ASPEN criteria. Most healthcare facilities are always/sometimes coding for malnutrition (78%); 19% of RD/RDNs are unsure of malnutrition coding activities within their practice settings. Large, academic healthcare facilities are more likely to be coding for malnutrition (P < .01). The top 4 barriers to coding malnutrition include lack of PCP documentation of malnutrition diagnosis for coding (47%), incorrect selection of code reflecting the proper malnutrition diagnosis (39%), RD/RDN lack of training in nutrition-focused physical exam (34%), and disagreement of proper malnutrition diagnosis between disciplines (38%).

Conclusions: Practices on identification of malnutrition vary between RD/RDNs and practice settings. The majority of RD/RDNs routinely diagnose malnutrition using the Academy/ASPEN criteria. However, smaller/nonacademic hospitals are less likely to diagnose malnutrition using the approved criteria. Several barriers to proper coding of malnutrition coding were identified. Further training and education opportunities are needed.

DOI: 10.1177/0148607116686023