Extended criteria (experimental).
This is the broader ten-condition engine, kept as a secondary area. It shows ICD-10-CM codes and illustrative grouping effects
for CDI staff. The primary surface is Before you sign (kidney, measurement only).
All extended pages.
← Back to the worklist · Whole encounter ENC-00039
Sana Pemberton: Malnutrition
ENC-00039 · 67F · Cardiology · admitted Mon Nov 09, 2026 04:36 PM · in hospital · attending Dr. Wes Merriweather · resident Dr. Keira Upfield
Clinical judgement required Clinical judgement required Open
In hospital: concurrent review Resident note awaiting attending cosign
Clinical judgement required: Only one consensus characteristic documented; two are required.
Documented vs supported
- Documented
- “malnutrition” · E46 Unspecified protein-calorie malnutrition
- Criteria support
- no conclusion: clinical judgement required
- Outcome
- Only one consensus characteristic documented; two are required
- Rule
- Malnutrition severity (ASPEN/Academy 2012 consensus characteristics) v2026.11-1
- Published source
- Consensus statement: Academy of Nutrition and Dietetics and ASPEN: characteristics recommended for the identification and documentation of adult malnutrition (White JV et al., J Acad Nutr Diet 2012;112:730-738) (2012), Table: clinical characteristics; at least two of six characteristics; acute illness and chronic illness contexts · source (checked 2026-11-14)
- Contested
- GLIM (2019) is an alternative, internationally endorsed framework with different thresholds; an organization must choose one per policy. This rule encodes ASPEN/Academy 2012 and lists GLIM as the alternative.
Clinical judgement required. The rule does not conclude here. A CDI specialist may send an open query or dismiss the finding; nothing is proposed as fact.
Effect if the clinician agrees (illustrative)
- Change
- no projected change (clinician judgement)
- Secondary-diagnosis level
- CC → —
- MS-DRG (illustrative)
- 292 Heart failure and shock with CC → 292 Heart failure and shock with CC
- Relative weight
- 0.8490 → 0.8490 (+0.0000)
- Codes before
- I50.33, E46, E78.5
- Codes after
- I50.33, E46, E78.5
All open gaps on this encounter together: MS-DRG 292 → 291 (RW +0.4348).
CC/MCC status, CC exclusions (subset) and relative weights from the public CMS FY2026 IPPS final rule tables (5, 6I, 6J, 6K). This is not a grouper and not a payment estimate. Queries never mention any of this.
Severity documentation index change SIMULATED
0.0 points
SIMULATED: Illustrative severity weights (MCC = 1.0, CC = 0.5, non-CC = 0) summed over secondary diagnoses; not a validated risk-adjustment model and not a measured effect.
Evidence
Structured values are read by code from the cited rows. Note facts are shown only when the model's quote was found verbatim in the note.
| Input | Value | Source |
|---|---|---|
| Context from the dietitian assessment ("acute" or "chronic" illness) | acute |
“Context: acute illness”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Sana Pemberton MRN: MRN35397651
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subc … |
| Energy intake as % of estimated need | 60.0 |
“estimated energy intake 60% of needs for 9 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Sana Pemberton MRN: MRN35397651
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
… |
| Duration of reduced intake (days) | 9.0 |
“estimated energy intake 60% of needs for 9 days”
Show the quote in the noteNUTRITION ASSESSMENT (Registered Dietitian)
Patient: Sana Pemberton MRN: MRN35397651
Context: acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
… |
| Subcutaneous fat loss (0 none, 1 mild, 2 moderate, 3 severe) | 0 |
“no loss of subcutaneous fat”
Show the quote in the note… : acute illness
Intake: estimated energy intake 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: at risk; continue calorie counts. |
| Muscle mass loss (0-3) | 0 |
“no muscle wasting”
Show the quote in the note… ated energy intake 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: at risk; continue calorie counts. |
| Fluid accumulation (0-3) | 0 |
“no fluid accumulation”
Show the quote in the note… 60% of needs for 9 days.
Weight history: weight stable over the past 3 months.
Nutrition-focused physical exam: no loss of subcutaneous fat; no muscle wasting; no fluid accumulation.
Assessment: at risk; continue calorie counts. |
Rule trace (inputs, thresholds, outcome)
| Step | Expression | Inputs and thresholds read | Result |
|---|---|---|---|
| derived: a_sev_intake | intake_pct <= t.a_sev_intake_pct and intake_days >= t.a_sev_intake_days |
intake_days=9.0, intake_pct=60.0, t.a_sev_intake_days=5, t.a_sev_intake_pct=50 | false |
| derived: a_mod_intake | intake_pct < t.a_mod_intake_pct and intake_days > t.a_mod_intake_days |
intake_days=9.0, intake_pct=60.0, t.a_mod_intake_days=7, t.a_mod_intake_pct=75 | true |
| derived: a_sev_wt | (wt_loss_days <= 7 and wt_loss_pct > 2) or (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) |
wt_loss_days=unknown, wt_loss_pct=unknown | unknown |
| derived: a_mod_wt | (wt_loss_days <= 7 and wt_loss_pct >= 1) or (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) |
wt_loss_days=unknown, wt_loss_pct=unknown | unknown |
| derived: c_sev_intake | intake_pct <= t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=9.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75 | false |
| derived: c_mod_intake | intake_pct < t.c_intake_pct and intake_days >= t.c_intake_days |
intake_days=9.0, intake_pct=60.0, t.c_intake_days=30, t.c_intake_pct=75 | false |
| derived: c_sev_wt | (wt_loss_days <= 31 and wt_loss_pct > 5) or (wt_loss_days <= 92 and wt_loss_pct > 7.5) or (wt_loss_days <= 183 and wt_loss_pct > 10) or (wt_loss_days <= 366 and wt_loss_pct > 20) |
wt_loss_days=unknown, wt_loss_pct=unknown | unknown |
| derived: c_mod_wt | (wt_loss_days <= 31 and wt_loss_pct >= 5) or (wt_loss_days <= 92 and wt_loss_pct >= 7.5) or (wt_loss_days <= 183 and wt_loss_pct >= 10) or (wt_loss_days <= 366 and wt_loss_pct >= 20) |
wt_loss_days=unknown, wt_loss_pct=unknown | unknown |
| derived: n_assessed | known(intake_pct, wt_loss_pct, fat_loss, muscle_loss, fluid, grip_reduced) |
fat_loss=0, fluid=0, grip_reduced=unknown, intake_pct=60.0, muscle_loss=0, wt_loss_pct=unknown | 4 |
| derived: n_severe | case(nutr_context == 'acute', count(a_sev_intake, a_sev_wt, fat_loss >= 2, muscle_loss >= 2, fluid >= 2, grip_reduced), nutr_context == 'chronic', count(c_sev_intake, c_sev_wt, fat_loss >= 3, muscle_loss >= 3, fluid >= 3, grip_reduced), null) |
a_sev_intake=False, a_sev_wt=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute | 0 |
| derived: n_moderate | case(nutr_context == 'acute', count(a_sev_intake or a_mod_intake, a_sev_wt or a_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), nutr_context == 'chronic', count(c_sev_intake or c_mod_intake, c_sev_wt or c_mod_wt, fat_loss >= 1, muscle_loss >= 1, fluid >= 1, grip_reduced), null) |
a_mod_intake=True, a_mod_wt=unknown, a_sev_intake=False, a_sev_wt=unknown, c_mod_intake=False, c_mod_wt=unknown, c_sev_intake=False, c_sev_wt=unknown, fat_loss=0, fluid=0, grip_reduced=unknown, muscle_loss=0, nutr_context=acute | 1 |
| outcome: severe | n_severe >= 2 |
n_severe=0 | false |
| outcome: moderate | n_moderate >= 2 |
n_moderate=1 | false |
| outcome: one_characteristic | n_moderate == 1 |
n_moderate=1 | true |
Documentation query
Title and question drafted by model clockworks-mock (audit entry #2030); clinical indicators and answer options assembled by code from the rule and the record.
Sign in to act. Sign in as a demo user (a CDI specialist sends queries).
DOCUMENTATION QUERY (draft) Title: Clarification request: nutrition documentation Encounter: ENC-00039 Patient: Sana Pemberton To: Dr. Wes Merriweather Clinical indicators from the health record: - Documented in the record: "malnutrition" [Progress note DOC-000132] - "Context: acute illness" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 4] - "estimated energy intake 60% of needs for 9 days" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 5] - "estimated energy intake 60% of needs for 9 days" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 5] - "no loss of subcutaneous fat" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 7] - "no muscle wasting" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 7] - "no fluid accumulation" (2026-11-10 19:36) [Nutrition assessment DOC-000129, p. 1, line 7] Question: Could you review the nutrition assessment above and clarify any related diagnosis, if clinically appropriate? Response options (select one or write your own): ( ) Other (please specify): ____________ ( ) Unable to determine Please respond based on your independent clinical judgement. Any response, including "unable to determine", is acceptable. This query and your response are kept as part of the health record.
Other findings on this encounter
- Acute blood loss anaemia · Specificity gap Criteria support Acute blood loss anemia (D62); no corresponding diagnosis is documented.
- Pressure injury · Specificity gap Criteria support Pressure injury of sacral region, stage 4 (L89.154); no corresponding diagnosis is documented.
History
| Seq | When (UTC) | Actor | Action | Entities | Decision / reason | Model / hashes |
|---|---|---|---|---|---|---|
| 2030 | 2026-11-14T20:57:23 | system:llm system |
llm.call |
ENC-00039, ENC-00039.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry cf309d57cf68 |
| 1204 | 2026-11-14T19:24:28 | system:llm system |
llm.call |
ENC-00039, ENC-00039.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry 1c933942f166 |
| 462 | 2026-11-14T18:29:03 | system:llm system |
llm.call |
ENC-00039, ENC-00039.malnutrition | — | clockworks-mock mock-1/exactdx.draft_query@1 prompt b16b1ad157cf output 6db30627be78 entry ff79ef1847fd |