New Global Malnutrition Definition (GLIM)

In 2018, the Global Leadership Initiative on Malnutrition (GLIM) published in the Journal of Parenteral and Enteral Nutrition a consensus recommendation “GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community.”

Leaders of the initiative included representatives from the American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism, Latin American Nutritional Federation, Parenteral and Enteral Nutrition Society of Asia.

The purpose of GLIM is to reach a global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition in clinical settings.

The GLIM definition of malnutrition is based on 5 diagnostic criteria: 3 phenotypic (clinical findings) and 2 etiologic (causes).

The diagnosis of malnutrition requires at least 1 phenotypic criterion and 1 etiologic criterion.

Get our CDI Pocket Guide® for more information about the GLIM and ASPEN criteria for malnutrition. 

GLIM Malnutrition criteria

Phenotypic Criteria
1.  Weight loss % (unintended) 5% < 6 months, or
10% > 6 months
2.  Low BMI < 20 if < 70 yrs, or < 22 if > 70 yrs
3.  Reduced Muscle Mass Reduced by objective measures and/or physical exam
Etiologic Criteria
1.  Reduced Nutritional Intake < 50% of requirement > 1 week, or
Any reduction > 2 weeks, or
Chronic GI disorders with adverse nutrition impact
2.  Inflammation Chronic disease, or
Acute disease/injury with severe systemic inflammation, or
Socioeconomic/environmental starvation

Severity of malnutrition is based on phenotypic criteria only, and requires 1 phenotypic criteria that meets these thresholds:

Moderate (stage 1) malnutrition
1.  Weight loss %
(unintended)
5%─10% < 6 months, or
10%─20% > 6 months
2.  Low BMI < 20 if < 70 yrs, or < 22 if > 70 yrs
3.  Reduced Muscle Mass Mild-to-moderate deficit (per validated assessment methods*)
Severe (stage 2) malnutrition
1.  Weight loss %
(unintended)
> 10% < 6 months, or
> 20% > 6 months
2.  Low BMI < 18.5 if < 70 yrs, or
< 20 if > 70 yrs
3.  Reduced Muscle Mass Severe deficit (per validated assessment methods*)

*To measure muscle mass, GLIM recommends use of DEXA, bio-electrical impedence analysis (BIA), ultrasound, CT or MRI, but these are costly and impractical.  As an alternative, calf or arm circumference and physical exam findings may be used along with calibrated hand-grip strength which is correlated with muscle mass.

The GLIM criteria offer some advantages over the 2012 ASPEN Malnutrition Consensus criteria. While the ASPEN criteria is effective for diagnosing malnutrition, it was less so for defining severe malnutrition. The GLIM criteria are less subjective, more clinically intuitive and include weight loss, muscle mass, and BMI parameters that are more consistent with the traditional concepts of non-severe and severe malnutrition.

For example, muscle mass assessment is much more robust than in ASPEN recommending calf/arm circumference, physical findings and measurement of hand grip strength. More stringent criteria for severe malnutrition reduces over-diagnosis and compliance exposure.

In addition, the GLIM Etiology criteria for acute disease/injury includes confirmation of severe systemic inflammation (in contrast to ASPEN). This is a much-needed provision that incorporates recent research showing the central role systemic inflammation plays in the development of malnutrition. Biomarkers are recommended to confirm chronic or severe systemic inflammation. C-reactive protein (CRP) is preferred but low albumin/prealbumin are also included. While not specifically mentioned by GLIM, SIRS criteria could also be used to identify systemic inflammation.

The GLIM BMI criteria may at first seem overstated since the CDC definition of "normal" in the general healthy population is 18.5 to 24.9. However, world-wide nutritional research has validated the contribution of GLIM BMI ranges to malnutrition and confirmed their adverse health consequences in acutely and chronically ill hospitalized patients.

From a coding perspective, GLIM identifies only moderate and severe malnutrition. Malnutrition stage is not an indexed term so if stage 1 is documented, code E46 (unspecified malnutrition) may be used. If only stage 2 is documented, it must be clarified as severe for correct coding of E43 (severe malnutrition).

Copyright (c) 2019-2022 Pinson & Tang

CMS-HCC Listing Version 23.0 with ICD-10 Codes

CMS-HCC Version 23 including 83 HCCs with HCC weights and ICD-10 codes.

V23 CMS-HCC ICD-10 codes

Myocardial Infarction: What's New

Understanding the different types of myocardial infarction can be challenging.  In this article, we share the authoritative definitions for each of the six types of myocardial infarction and explain their distinct differences to help you guide proper physician documentation, correct coding, and successfully query your physicians.

The table below lists the six types of myocardial infarction (MI) based on the Third Universal Definition of Myocardial Infarction with corresponding ICD-10 codes for 2018:

Type Description ICD-10 Code
1 Spontaneous MI primarily due to coronary artery disease (CAD)
STEMI (Q-wave)
NSTEMI
I21.0-I21.3 (initial)
I22.0-I22.9 (subseq)
I21.4
2 MI due to supply/demand mismatch I21.A1
3 Death from MI when biomarkers not available I21.A9
4a MI related to percutaneous coronary intervention I21.A9
4b MI related to stent thrombosis I21.A9
5 MI related to coronary artery bypass grafting I21.A9

Types 1 and 2 are by far the most commonly encountered in clinical practice and defined as:

Cardiac troponin (I or T) is the most reliable biomarker for all types of MI because it has high myocardial specificity and high clinical sensitivity. Other cardiac biomarkers include MB fraction of creatinine phosphokinase (CK-MB) and myoglobin.

Get our CDI Pocket Guide® for more information about myocardial injury, ischemia and infarction.  


Type 1 MI is the classic spontaneous MI primarily due to CAD with atherosclerotic plaque rupture, ulceration, fissuring, erosion, or dissection causing coronary thrombosis.  Occasionally Type 1 occurs in the absence of CAD with spontaneous thrombosis of a coronary artery (particularly in women). Type 1 includes both STEMI (Q-wave) and NSTEMI.

Treatment of STEMI usually requires immediate reperfusion therapy or percutaneous coronary intervention (PCI), such as coronary stent.  NSTEMI treatment usually includes: nitroglycerin, aspirin, Plavix, a beta-blocker (e.g. atenolol, metoprolol), heparin or Lovenox, and Integrilin or Aggrastat.

Type 1 MI (STEMI and NSTEMI) is assigned to one of several codes in category I21 having specificity for the location of STEMI.  NSTEMI is not specified to location and is assigned to code I21.4.

Type 2 MI is commonly known as supply/demand infarction where the supply of oxygenated blood to the myocardium does not meet the physiologic demand for oxygen (supply/demand mismatch or ischemic imbalance), causing myocardial necrosis primarily due to a condition other than CAD.  Common causes include severe anemia, rapid tachyarrhythmia, hypertensive emergency, and shock states.  Also included as Type 2 are non-thrombotic occlusions like coronary spasm or embolism from another site.

Treatment of Type II MI is directed at the cause, not the MI itself, for example fluid resuscitation, anti-arrhythmics, blood transfusion, IV anti-hypertensives.

Type 2 MI (either initial or subsequent) is assigned to one code (I21.A1). The code also includes any mention of MI or infarction with “demand ischemia” or “ischemic imbalance.” However, a diagnosis of “demand ischemia” alone is assigned to code I24.8, other forms of acute ischemic heart disease, comparable to unstable angina primarily due to CAD.

Now that a specific code exists for Type 2 MI (supply/demand infarction), it should not be described as NSTEMI, which is a Type 1 MI primarily due to CAD.  Incorrectly documenting NSTEMI rather than Type 2 results in many undesirable consequences for providers, patients, classification and data analysis.

Type 2 MI vs. Demand Ischemia.  Demand ischemia is supposed to be reserved for supply/demand mismatch causing ischemia (without necrosis) where biomarkers remain below the 99th percentile of the upper limit of reference range.  The term “demand ischemia” may be used indiscriminately even when patients experience Troponin or CK-MB release above the 99th percentile, which is technically a Type 2 MI.

A physician query is appropriate for the possibility of Type 2 MI when the diagnosis of demand ischemia is associated with elevated troponins above 99th percentile range.  It may be necessary to verify what the 99th percentile reference range is for your hospital’s lab.

Example:  A patient is admitted with acute GI bleed, severe anemia, hypotension and chest pain. Troponins 0.17, 0.20, 0.225 (all greater than 99th percentile).  Treatment is control of bleeding, fluid resuscitation, and blood transfusion.  The cardiologist diagnosed “demand ischemia with elevated troponins.”  The circumstances in this case clearly confirm Type 2 MI with treatment directed at the underlying causes and not a coronary thrombosis, and the physician should be queried.

Type 3 MI is rarely encountered since biomarkers are usually obtained, but sometimes the patient dies of an MI before the biomarkers have risen above the 99th percentile of the upper limit of reference range.  The MI may have been identified by symptoms that suggested MI and were associated with presumed new changes on electrocardiogram, such as Q-waves, ST elevation, or new left bundle-branch block.

Type 4 MI identifies a complication related to percutaneous coronary intervention (PCI) or a coronary stent. Type 4a is an MI related to PCI. It has a complicated technical definition with six separate criteria, including one that requires an elevation of cardiac troponin to a level five times greater than the 99th percentile of the upper limit of reference range from a normal pre-procedural baseline. Type 4b is simply a Type 1 MI associated with acute stent thrombosis.

Type 5 is MI related to coronary artery bypass grafting. It also has a complex technical definition with four separate diagnostic criteria, one of which is an elevation of biomarkers  to a level 10 times greater than the 99th percentile of the upper limit of reference range from a normal preoperative baseline.

Types 3, 4a, 4b, and 5 are lumped together in a single code (I21.A9) that includes either initial or subsequent MI.  This a little disappointing since distinction among these Types would be really useful for the national health care database, allowing precise, meaningful analysis of clinical outcomes, resource utilization, and other important data on these different Types of MI.

A Type 4c MI is also identified by ICD-10 under code I21.A9. Type 4c is not included in the Universal Definition Types but is recognized for use in clinical trials to describe infarction due to PCI-related restenosis.


ICD-10 Coding.  Coding of the various Types of MI is not difficult once the definitions and causes are understood. All codes for all Types of MI are classified as MCCs and demand ischemia (without MI) is a CC.

An MI is coded as acute for a period of four weeks following onset for both the initial episode of care or for continued care of an MI that occurred within the past 4 weeks; after that it is assigned code I25.2 (old MI).  A subsequent MI (“reinfarction”) is defined as another MI occurring within 4 weeks of the occurrence of a previous “initial” MI.  Whenever a subsequent MI occurs, two codes are assigned: a subsequent MI code in category I22 and initial MI code (I21.-).


Summary.  The Third Universal Definition of Myocardial Infarction has defined six Types of MI. The two most commonly encountered are Type 1 (STEMI and NSTEMI) primarily due to CAD and Type 2 primarily due to a condition other than CAD.  Types 3-5 are much less common and describe unique circumstances primarily related to procedures.

Documentation of the specific Type of MI is clinically important and essential for correct coding, billing, reimbursement, and reporting to the national health care database. An accurate database allows precise, meaningful analysis of clinical outcomes, resource utilization, and other important data.

Always query regarding the possibility of Type 2 MI when the diagnosis of demand ischemia is associated with elevated troponins above 99th percentile range, and for NSTEMI when associated with unstable angina or acute coronary syndrome and elevated troponins above 99th percentile range.

It may be necessary to educate your hospitalists and cardiologists regarding the various MI definitions, particularly for Type 2 MI.  A clinically correct distinction between Type 2 MI and demand ischemia is necessary to accurately describe the clinical circumstances.


Reference: Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation 2012;126:2020-35.


Sample Query for Demand Ischemia with Elevated Troponins

Documentation in the medical record indicates that this patient has been admitted with or
diagnosed as having ___________________________.

The following is also documented in the medical record [include only those that apply]:

Based on your medical judgment, can you further clarify in the progress notes which, if any,
of the following this condition is intended to indicate:

In responding to this request, please exercise your independent professional judgment. The
fact that a question is asked does not imply that any particular diagnosis is desired or
expected.

Copyright (c) 2018 Pinson & Tang

MCC-CC Listings - MS-DRG FY2018 (Tables 6I & 6J)

Complete MCC-CC listing for FY2018.

FY2018 Complete MCC-CC List

 

SEP-1 Early Management Bundle, Severe Sepsis, Septic Shock Specifications 2017

The CMS Hospital Inpatient Quality Reporting (IQR) severe sepsis management measure (called SEP-1) defines severe sepsis as SIRS due to infection with acute organ dysfunction and does not follow Sepsis-3 criteria.

The CMS-defined organ dysfunction criteria are:  SBP < 90 or MAP < 65, SBP decrease > 40 from baseline, Bilateral pulmonary infiltrates with P/F ratio < 300, Creatinine > 2.0 or urine output < 0.5, Bilirubin > 2, Platelet count < 100,000, Coagulopathy (INR> 1.5 or aPTT > 60 secs, Lactate > 2.

SEP-1 Early Management Bundle, Severe Sepsis, Septic Shock Specifications 2017

Important CDI & Coding Updates 2017

COPD and Pneumonia

The requirement for code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) to be coded first when a patient has pneumonia and COPD has been eliminated as of October 1, 2017.

The 2018 version of ICD-10-CM replaced the “use additional code” with “code also”.  According to OCG Section I.A.17, the Code Also note “does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.”

We are now back to where the selection of principal diagnosis between COPD and Pneumonia will be “determined by the circumstances of admission, diagnostic workup and/or therapy provided” pursuant to OCG Section II (Selection of Principal Diagnosis).

Get our CDI Pocket Guide® for your coding and CDI updates.


Type 2 MI

With the 2018 ICD-10-CM, we finally have codes to identify Type 2 MI (primarily due to supply/demand mismatch) and make the important distinction between it and Type 1 (primarily due to coronary artery disease). In the past, Type 2 was coded as NSTEMI creating many practical problems especially since these two types of MI have completely different causes, pathophysiology, implications, outcomes and management.

Furthermore, this situation improperly labeled patients with supply/demand mismatch (Type 2) as having acute coronary thrombosis primarily due to coronary artery disease causing significant inaccuracy with consequences for patients, clinicians, and the healthcare data base statistics and analysis.

Type 2 MI (whether new initial or subsequent) is assigned to one code (I21.A1). The code also includes any description of MI being due to “demand ischemia” or “ischemic imbalance”. As an MCC, the diagnosis of Type 2 MI has major severity impact affecting DRG assignment and quality reporting, just like Type 1 MI.

Now that a specific code exists for Type 2 MI, a supply/demand infarction should not be documented as NSTEMI since that term is reserved for MI due to coronary artery disease requiring aggressive intervention directed at thrombosis and occlusion of a coronary artery. Type 2 is managed by treating the underlying cause.

A diagnosis of “demand ischemia” has always been problematic. It is still assigned to code I24.8, Other forms of acute ischemic heart disease (a CC).  Demand ischemia is supposed to be reserved for supply/demand mismatch causing ischemia without necrosis where biomarkers remain below the 99th percentile of the upper limit of reference range, but is often used by clinicians to describe what technically Type 2 MI is with biomarkers above the 99th percentile. A clinically correct distinction between demand ischemia and Type 2 MI is an important diagnostic and coding concern.


Encephalopathy due to Stroke

 Coding Clinic Second Quarter 2017 responded to a question regarding whether or encephalopathy would be coded separately or considered inherent to a cerebral infarction when diagnosed with encephalopathy secondary to an acute lacunar infarct.

Coding clinic instructions were to “Assign code G93.49, other encephalopathy, for encephalopathy that occurs secondary to an acute cerebrovascular accident/stroke. Although the encephalopathy is associated with an acute lacunar infarct, it is not inherent, and therefore is coded when it occurs.

There are two distinct categories of encephalopathy: acute and chronic.  Many sources confuse and confound these categories, lumping them together as one. However, the chronic encephalopathies are characterized by a chronic mental status alteration that, in most cases, is slowly progressive. They result from permanent, usually irreversible, diffuse structural changes in the brain.

The vast majority of encephalopathy cases encountered in the inpatient setting are acute. Acute encephalopathy is characterized by an acute, diffuse, functional alteration of mental status due to underlying systemic factors rather than local intracranial processes. It is reversible when these abnormalities are corrected, with a return to baseline mental status.  Acute encephalopathy may be further identified as toxic, metabolic, or toxic-metabolic depending on its systemic cause.

Ordinarily, from a clinical standpoint, a mental status change associated with focal intracranial processes (like CVA) is more an alteration of consciousness and responsiveness in the spectrum of coma, obtundation, and lethargy – objectively measured using the Glasgow Coma Scale (GCS) scoring – and not an encephalopathic process.

The unsettled question remains whether “encephalopathy due to CVA” is a clinically valid diagnosis that can be compliantly coded on claims, since Coding Clinic disclaims any authority to assert or establish clinical diagnostic definitions or standards. Based on the definitions and descriptions above of what encephalopathy is and is not, the diagnosis of encephalopathy due to CVA could be challenged.  On the other hand, obtaining a GCS may reveal one of the component scores severe enough to qualify as an MCC.


Functional Quadriplegia

Although the FY2018 Official Coding Guidelines no longer include the paragraph regarding functional quadriplegia, it is still a valid diagnosis and ICD-10-CM code.

R53.2  Functional quadriplegia
Complete immobility due to severe physical disability or frailty
Excludes 1:
Frailty (R54)
Hysterical paralysis (F44.4)
Immobility syndrome (M62.3)
Neurologic quadriplegia (G82.5-)
Quadriplegia (G82.50)

ICD-10 Codes for CMS-HCC Models

ICD-10 Codes for CMS-HCC Models includes the CMS-HCC ICD10 codes, code description, category and weight, and also includes the HCC categories for the RxHCC and PACE/ESRD Models.

Sepsis-3 SOFA Point Scale

Sepsis-3 SOFA Point Scale table.

Sepsis-3 SOFA Point Scale

Inpatient Only Procedure List 2017

2017 Final Addendum E.10.20.16

CMS Responds to New Sepsis-3 Definition

The newly proposed Sepsis-3 definition has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association (JAMA) on February 23, 2016.  That controversial definition discarded the concept of SIRS as the basis for defining sepsis and eliminated the distinction between sepsis and severe sepsis.
 
Now JAMA has just published a letter in the July 26 issue submitted by three physician representatives of CMS announcing that CMS will not change the sepsis definitions used in its SEP-1 sepsis management inpatient quality measure implemented October 1, 2015.  The definitions used in the SEP-1 measure (NQF Sepsis #0500), which CMS described as "widespread and understood", rely on sepsis as SIRS due to an infection and severe sepsis as sepsis with acute organ dysfunction. 
 
CMS pointed out that clinical practice measures require "extensive real-world field testing to assess reliability, usability, and feasibility", and that "the SEP-1 measure underwent more than eight years of development and critical review" and is supported by a large body of clinical evidence.
 
While welcoming "new research and innovative thinking", the letter emphasized that "prior to changing the widespread and understood definitions used in SEP-1, rigorous clinical investigation will be required...".
 
Other reservations concerning the proposed Sepsis-3 definitions expressed by CMS in the letter included the potential for delayed diagnosis of sepsis, a disruption of a "15-year trend toward further reduction in sepsis mortality", and impeding ongoing quality improvement efforts.
The CMS letter expresses the same concerns voiced by the healthcare community at large since the new Sepsis-3 proposed definitions were first published.  Many other letters from across the country and the world were also published by JAMA together with the CMS response expressing concerns that focused on potential flaws in methods and statistical analysis and the need for prospective studies to substantiate the "real-world" clinical validity of the new Sepsis-3 definitions.  CMS will continue to track further research that the new "proposed definitions will inspire."
References:
  1. CMS JAMA editorial letter  (requires membership for purchase). 
  2. Fact Sheet SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock
  3. NQF Sepsis #0500 - Severe Sepsis and Septic Shock Management Bundlepages 20-21.