Clinical nutrition update

Terese Scollard, MBA, RDN, LD, FAND, regional clinical nutrition manager

Consensus definition of malnutrition for adults
The Epic workflow and medical coding for adult malnutrition includes a physician electronic review, documentation, clarification and a signature. The physician is not co-signing the dietitian's nutritional evaluation, even though the Epic work flow may appear that way. The signature and documentation step causes efficient, effective flow of patient data for clinical analysis, billing and CMS compliance.

The Providence Medical Nutrition Subcommittee of Pharmacy and Therapeutics periodically reviews this process with medical coding to assure accuracy and compliance. Information and resources are found here and here.

Physicians are encouraged to consider the Consensus malnutrition characteristics to diagnose patients in inpatient and ambulatory settings. Disease-related malnutrition occurs at any BMI and is a cause and consequence of disease.

For patients age 65 or older, a BMI less than 23 or 22 is generally considered low, especially in light of disease (except in persons of Asian descent). Contact your unit dietitian or Terese Scollard if you have questions or would like an in-service.

Nutrition coding alert
"Severe protein calorie malnutrition" is the correct language for adult patients at the severe level of acute, chronic or starvation disease-related malnutrition. This language ensures the coders' Encoder searches and attaches to ICD code 262, which is in compliance for adults.

The phrase "severe malnutrition," however, causes the Encoder computer search to attach to ICD-9 code 261 or 260, which are only to be used for pediatrics. This becomes a compliance error in adult coding. More detail and ICD-10 crosswalk are available here.

Epic has smart phrases (dot phrases) available to shorten writing:
.pcm = protein-calorie malnutrition
.pcmma = moderate acute protein-calorie malnutrition
.pcmmc = moderate chronic protein-calorie malnutrition
.pcmmi = mild protein-calorie malnutrition (note: No clinical criteria established)
.pcmms = moderate starvation or social protein-calorie malnutrition
.pcmsa = severe acute protein-calorie malnutrition
.pcmsc = severe chronic protein-calorie malnutrition
.pcmss = severe starvation or social-protein calorie malnutrition

Nutrition risk screening tools
Various tools are available online, in hard copy or as apps. They can be used by patients themselves, by professionals or by office staff to identify patients who are at nutrition risk before surgery or at any stage of care.

Two tools with good validity and reliability are the Patient Generated Subjective Global Assessment-Abridged and the Mini Nutrition Assessment-Self for Seniors. For information on referring ambulatory patients to outpatient nutrition counseling, click here. To learn more or to try out these tools and others, please email Terese Scollard.

Nutritional preparation for surgery
To be better prepared for surgery, patients may need nutritional improvements. Our outpatient registered dietitian nutritionists can help patients who need to lose weight healthfully before surgery, reverse unintended weight loss, gain weight, improve their diet quality, manage lipids and blood sugar, and control pre-diabetes. Most insurance plans cover this service; however, patients should contact their insurance company for specific details. A special presurgical drink (Impact Advance Recovery) is available at the Medical Office Building Pharmacy at Providence St. Vincent Medical Center and at the Plaza Pharmacy at Providence Portland Medical Center. You can find referral information here.

Tube feeding and oral supplement formulary
Providence Health & Services has a vendor contract for tube feedings and oral nutritional supplements used in acute care and in-home/community settings. There are no changes to Epic acute care order sets. Contact your site dietitian for details. You may view the formulary here.

Outpatient nutrition services: Epic referrals
Through Epic, you may refer patients for consultations with our registered and licensed outpatient dietitians at any of our eight Providence hospitals in Oregon.

Providence St. Vincent Medical Center = OSV OP Nutrition (located at PSVMC) 503-216-2368
Providence Portland Medical Center = OPH OP Nutrition (located PPMC on 1R) 503-215-5160
Providence Milwaukie Hospital = OMW OP Nutrition (located at PMH) 503-215-5160
Providence Willamette Falls Medical Center = OMW OP Nutrition (located at PMH) 503-215-5160
Providence Newberg Medical Center = ONB OP Nutrition (located at PNMC) 503-537-1555
Providence Seaside Hospital = OSS OP Nutrition (located at PSH) 503-717-7000
Providence Hood River Memorial Hospital = OHR OP Nutrition (located at PHRMH) 541-387-6379
Providence Medford Medical Center = OMD OP Nutrition (located at PMMC) 541-732-5288

If you have questions or comments, I invite you to contact me.