title: Malnutrition: The Importance of Identification, Documentation, and Coding in the Acute Care Setting.
abstract: Malnutrition is a significant issue in the hospital setting. This cross-sectional, observational study determined the prevalence of malnutrition amongst 189 adult inpatients in a teaching hospital using the Patient-Generated Subjective Global Assessment tool and compared data to control groups for coding of malnutrition to determine the estimated unclaimed financial reimbursement associated with this comorbidity. Fifty-three percent of inpatients were classified as malnourished. Significant associations were found between malnutrition and increasing age, decreasing body mass index, and increased length of stay. Ninety-eight percent of malnourished patients were coded as malnourished in medical records. The results of the medical history audit of patients in control groups showed that between 0.9 and 5.4% of patients were coded as malnourished which is remarkably lower than the 52% of patients who were coded as malnourished from the point prevalence study data. This is most likely to be primarily due to lack of identification. The estimated unclaimed annual financial reimbursement due to undiagnosed or undocumented malnutrition based on the point prevalence study was AU$8,536,200. The study found that half the patients were malnourished, with older adults being particularly vulnerable. It is imperative that malnutrition is diagnosed and accurately documented and coded, so appropriate coding, funding reimbursement, and treatment can occur.
authors: Faculty of Health, University of Canberra, Canberra, ACT 2601, Australia.
authors: Jane
authors: 0000-0003-0586-3203
authors: J
authors: Kellett
authors: Faculty of Health, University of Canberra, Canberra, ACT 2601, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD 4000, Australia.
authors: Greg
authors: G
authors: Kyle
authors: Faculty of Health, University of Canberra, Canberra, ACT 2601, Australia; School of Allied Health, LaTrobe University, Bundoora, Melbourne, VIC 3086, Australia.
authors: Catherine
authors: C
authors: Itsiopoulos
authors: Faculty of Health, University of Canberra, Canberra, ACT 2601, Australia.
authors: Mark
authors: M
authors: Naunton
authors: ACT Health, Garran, Canberra, ACT 2605, Australia.
authors: Narelle
authors: N
authors: Luff