Global Malnutrition Composite Score

Measure Information	2024 Reporting Period	2025 Reporting Period	2026 Reporting Period	2028 Reporting Period
Title	Global Malnutrition Composite Score	Global Malnutrition Composite Score	Malnutrition Care Score	Malnutrition Care Score
CMS eCQM ID	CMS986v2	CMS986v4	CMS986v5	CMS986v6
Short Name	GMCS	GMCS	MCS	MCS
CBE ID*	3592e	3592e	3592e	3592e
Measure Steward	Academy of Nutrition and Dietetics	Academy of Nutrition and Dietetics	Academy of Nutrition and Dietetics	Academy of Nutrition and Dietetics
Description	This measure assesses the percentage of hospitalizations for adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk or for a hospital dietitian referral order, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed.	This measure assesses the percentage of hospitalizations of adults aged 65 years and older at the start of the inpatient encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.	This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients are (1) screened for malnutrition risk or for a dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.	This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients (1) are screened for malnutrition risk or for a dietitian referral order to be placed, (2) are assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.
Measure Scoring	Continuous Variable	Continuous Variable	Continuous Variable	Continuous Variable
Measure Type	Intermediate Clinical Outcome	Intermediate Clinical Outcome	Intermediate Outcome	Intermediate Outcome
Stratification	None	None	None	None
Risk Adjustment	None	None	None	None
Rationale	The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at-risk of malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers. The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough physical assessment by registered dietitian nutritionists (RDN). The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician. The four component measures individually will only provide a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely nursing malnutrition risk screening and hand off to RDNs for appropriate nutritional assessment for patients at-risk of malnutrition during the current hospitalization. For patients identified with a moderate or severe malnutrition status from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professionals and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stay, and complications, as well as improved quality of life after hospitalization.	The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutritional status utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible provider as defined by CMS. The four measure observations individually will only provide a fraction of the necessary information on quality of care for patients at risk for or with malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely malnutrition risk screening and hand off to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with a moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of malnourished patients and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram, 2017).	Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) (Hudson, Chittams, Griffith, & Compher, 2018 and Mosquera et al., 2016) and significantly more patients with malnutrition have a LOS of greater than 7 days when compared to their well-nourished counterparts. Additionally, both higher rates of 30-day readmission and a significantly higher likelihood of 30-day readmission are observed in these patients (Mogensen et al., 2019; Hiller, Shaw, & Fabri, 2016; Mosquera et al., 2016). Lastly, hospitalized adults with malnutrition have an increased likelihood of death within 90 days of discharge (Hiller, Shaw, & Fabri, 2016). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes. The components of this measure are supported by clinical guidance that recommends (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score. High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of patients with malnutrition and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling demonstrates benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram et al., 2016).	Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) and a significantly higher likelihood of 30-day readmission when compared to their well-nourished counterparts (Lengfelder et al., 2022). Furthermore, hospitalized adults with malnutrition have an increased likelihood of all-cause mortality within 2 years of diagnosis (Trollebø et al., 2024) and an increase in in-hospital death when compared to patients without a diagnosis of malnutrition (Compher et al., 2024). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes. The components of this measure are supported by clinical guidance which recommend (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; and (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Swan et al., 2019). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score. High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that malnutrition pathways, which include a standardized protocol for screening, assessment, diagnosis, and care planning results in improved patient outcomes for malnourished patients (Pacetti et al., 2025).
Clinical Recommendation Statement	American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (A.S.P.E.N., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk of malnutrition is the first step in nutrition care as nutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Nutrition assessment is suggested for all patients who are identified to be at malnutrition risk by nutrition screening. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition support intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition support intervention in patients identified assessment as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.	American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, et al., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plants in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.	American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, Compher, Druyan, & ASPEN Board of Directors, 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.	American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller et al., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care, as malnutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Additionally, the Academy of Nutrition and Dietetics-ASPEN Indicators of Malnutrition (AAIM) provides a framework with significant validity in diagnosing malnutrition in hospitalized patients and supporting evidence that suggests that malnourished patients have more complications, longer hospitalizations, greater incidence of 30-day readmission, and higher incidence of mortality than patients with optimal nutrition status (Compher et al., 2024; Jimenez et al., 2024). Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications are reduced with increased nutrition support interventions.
Improvement Notation	Higher score indicates better quality of care	Higher score indicates better quality of care.	Increased score indicates improvement	Increased score indicates improvement
Definition	Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from the nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening is performed by a nursing professional, Registered Dietitian (RD), or Registered Dietitian Nutritionist (RDN). Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s). For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician/eligible clinician based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations and interventions that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, and is documented by the RD or RDN.	Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.	Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.	Malnutrition Risk Screening - The process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state, and federal guidelines. Nutrition Assessment - A systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status, related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by an RD or RDN. Malnutrition Diagnosis - A documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - A documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population-Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.
Guidance	This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater. Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed. Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed from a "Malnutrition Screening At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization. For Component Measure 1 and Component Measure 2, only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment". Component Measure 3: Inpatient hospitalizations for patients with a current documented "Malnutrition Diagnosis" as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current "Nutrition Assessment Status Severely Malnourished". Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current “Nutrition Assessment Status Severely Malnourished”. "Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations -For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. -For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period. "Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations: -For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. -For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period. "TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: -If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1. -If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2. The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4: -If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. -If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. -If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed. -If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours among individuals 65 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Initial Population	Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter	Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter.	Eligible encounters during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter	Eligible encounters that end during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter
Measure Population	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Measure Population Exclusion	None	None	Encounters with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter	Encounters for patients with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter
Measure Observation	This is a continuous variable measure. There are six measure observations for this measure. This measure is constructed of four clinically eligible components aggregated as an arithmetic average of eligible hospitalizations. A single measure population is used to calculate the "TotalMalnutritionComponentsScore" and "TotalMalnutritionCompositeScore as Percentage". The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater. "Measure Observation 1" = "Encounters with Malnutrition Risk Screening and Identified Result" "Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed with a current identified "Malnutrition Screening Not At Risk Result" or current "Malnutrition Screening At Risk Result". "Measure Observation 2" = "Encounter with Nutrition Assessment and Identified Status" "Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed with a current identified "Nutrition Assessment Status Not or Mildly Malnourished", "Nutrition Assessment Status Moderately Malnourished", or "Nutrition Assessment Status Severely Malnourished". "Measure Observation 3" = "Encounters with Malnutrition Diagnosis" "Measure Observation 3" identifies hospital encounters where a current "Malnutrition Diagnosis" was documented. “Measure Observation 4” = “Encounters with Nutrition Care Plan” "Measure Observation 4" identifies hospital encounters where a current "Nutrition Care Plan" was performed. "Population 5 Measure Observation TotalMalnutritionComponentsScore" = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4") "Population 5 Measure Observation "TotalMalnutritionComponentsScore" Calculations -For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. -For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period. "Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" = 100 * ("TotalMalnutritionComponentsScore" divided by "TotalMalnutritionCompositeScore Eligible Denominators"). Population 6 Measure Observation "TotalMalnutritionCompositeScore as Percentage" Calculations: -For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators. -For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period. "TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances: -If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1. -If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the “TotalMalnutritionCompositeScore Eligible Denominators” are 2. The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4: -If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed. -If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed. -If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed. -If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.	There are six measure observations for this measure. This measure is constructed of four clinically eligible components aggregated as an arithmetic average of eligible hospitalizations. A single measure population is used to calculate the "Total Malnutrition Components Score" and "Total Malnutrition Composite Score as Percentage". Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Hospital Dietitian Referral. "Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Hospital Dietitian Referral" "Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies a hospitalization where there is a Hospital Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not. Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization. "Measure Observation 2" is "Encounter with Nutrition Assessment and Identified Status" "Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished". Component Measure 3: Inpatient hospitalizations for patients with a documented "Malnutrition Diagnosis" as a result of a "Nutrition Assessment Status Finding of Moderately Malnourished" OR "Nutrition Assessment Status Finding of Severely Malnourished". "Measure Observation 3" is "Encounters with Malnutrition Diagnosis" "Measure Observation 3" identifies hospital encounters where a "Malnutrition Diagnosis" was active during the hospitalization (including preceding observation or emergency department encounters). Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Finding of Moderately Malnourished" OR current “Nutrition Assessment Status Finding of Severely Malnourished”. “Measure Observation 4” is “Encounters with Nutrition Care Plan” "Measure Observation 4" identifies hospital encounters where a "Nutrition Care Plan" was performed or authored during the hospitalization (including preceding observation or emergency department encounters). "Population 5 Measure Observation Total Malnutrition Components Score" Calculations -For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4. "Population 5 Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4") "Population 6 Measure Observation Total Malnutrition Composite Score as Percentage" Calculations: -For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences. "Population 6 Measure Observation Total Malnutrition Composite Score as Percentage" is 100 multiplied by ("Total Malnutrition Components Score" divided by "Total Malnutrition Composite Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent. "Total Malnutrition Composite Score Eligible Occurrences" is always 4 except in the following instances: -The "Total Malnutrition Composite Score Eligible Occurrences" is 1 if ---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered. - The "Total Malnutrition Composite Score Eligible Occurrences" are 2 ---If a "Nutrition Assessment" was performed and a "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished" was identified --- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was ordered OR a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed -For the reporting facility, the Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period. -For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Composite Score as Percentage" across all eligible hospitalizations during the measurement period.	Component Measure 1: Eligible encounters for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Dietitian Referral. "Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Dietitian Referral" "Measure Observation 1" identifies eligible encounters where a "Malnutrition Risk Screening" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies an eligible encounter where there is a Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not. Component Measure 2: Eligible encounters for patients with a documented "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" or a "Dietitian Referral" order from a physician or eligible clinician during the current encounter. "Measure Observation 2" is "Encounter With Most Recent Nutrition Assessment And Identified Status" "Measure Observation 2" identifies eligible encounters where a "Nutrition Assessment" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished". Component Measure 3: Eligible encounters for patients with a documented "Malnutrition Diagnosis" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or "Nutrition Assessment Status Finding of Severely Malnourished". "Measure Observation 3" is "Encounters with Malnutrition Diagnosis" "Measure Observation 3" identifies eligible encounters where a "Malnutrition Diagnosis" was active during the encounter (including preceding observation or emergency department encounters). Component Measure 4: Eligible encounters for patients with a documented "Nutrition Care Plan" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or “Nutrition Assessment Status Finding of Severely Malnourished”. “Measure Observation 4” is “Encounters with Nutrition Care Plan” "Measure Observation 4" identifies eligible encounters where a "Nutrition Care Plan" was performed or authored during the encounter (including preceding observation or emergency department encounters). Population 5 "Measure Observation Total Malnutrition Components Score" Calculations -For each eligible encounter, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4. Population 5 "Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4") Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" Calculations: -For each eligible encounter, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences. Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" is 100 multiplied by ("Measure Observation Total Malnutrition Components Score" divided by "Total Malnutrition Care Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent. "Total Malnutrition Care Score Eligible Occurrences" is always 4 except in the following instances: -The "Total Malnutrition Care Score Eligible Occurrences" is 1 if ---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was not ordered. - The "Total Malnutrition Care Score Eligible Occurrences" is 2 ---If the most recent "Nutrition Assessment" performed has a result of "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished". --- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was ordered or a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed.	Component Measure 1: Eligible encounters for patients with a current Malnutrition Risk Screening performed by an eligible healthcare clinician or with a Dietitian Referral. Measure Observation 1 is Encounters with Malnutrition Risk Screening or with a Dietitian Referral. Measure Observation 1 identifies eligible encounters where a Malnutrition Risk Screening was performed during the encounter (including associated observation or emergency department encounters) with an identified Malnutrition Screening Finding of Not At Risk or At Risk Result. It also identifies an eligible encounter where there is a Dietitian Referral, whether there is a Malnutrition Risk Screening performed or not. Component Measure 2: Eligible encounters for patients with a documented Nutrition Assessment performed by an RD/RDN, and with a Malnutrition Screening Finding of At Risk Result or a Dietitian Referral order from a physician or eligible clinician during the current encounter. Measure Observation 2 includes Encounters with Most Recent Nutrition Assessment and Identified Status if the encounter also contains Completed Malnutrition Risk Screening or Dietitian Referral. Measure Observation 2 identifies eligible encounters in which a malnutrition risk screening with an At Risk Result or a dietitian referral was completed during the encounter (or associated observation or emergency department encounters) and a Nutrition Assessment was subsequently completed with an identified Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished, Nutrition Assessment Status Finding of Moderately Malnourished, or Nutrition Assessment Status Finding of Severely Malnourished. Component Measure 3: Eligible encounters for patients with a documented Malnutrition Diagnosis based on the most recent Nutrition Assessment Finding of Moderately Malnourished or Severely Malnourished. Measure Observation 3 includes encounters with the most recent Nutrition Assessment and Identified Status of Moderately Malnourished or Severely Malnourished, that also identified an active medical malnutrition diagnosis during the encounter (including preceding observation or emergency department encounters) and a Malnutrition Risk Screening At Risk Result or with a Dietitian Referral. Component Measure 4: Eligible encounters for patients with a documented Nutrition Care Plan based on the most recent Nutrition Assessment Finding of Moderately Malnourished or Severely Malnourished. Measure Observation 4 identifies encounters with the most recent Nutrition Assessment and Identified Status of Moderately Malnourished or Severely Malnourished, that also include a documented Nutrition Care Plan and a Malnutrition Risk Screening At Risk Result or with a Dietitian Referral. Measure Observation 4 identifies eligible encounters where a Nutrition Care Plan was performed during the encounter (including preceding observation or emergency department encounters). Population 5 Measure Observation Total Malnutrition Components Score Calculations: For each eligible encounter, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4. Population 5 Measure Observation Total Malnutrition Components Score is (Measure Observation 1 plus Measure Observation 2 plus Measure Observation 3 plus Measure Observation 4). Population 6 Measure Observation Total Malnutrition Care Score as Percentage Calculations: For each eligible encounter, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences. Population 6 Measure Observation Total Malnutrition Care Score as Percentage is 100 multiplied by (Measure Observation Total Malnutrition Components Score divided by Total Malnutrition Care Score Eligible Occurrences). Possible values may be 0, 50, 75, or 100 percent. Total Malnutrition Care Score Eligible Occurrences is always 4 except in the following instances: The Total Malnutrition Care Score Eligible Occurrences is 1 if: A Malnutrition Risk Screening was performed, and a Malnutrition Screening Finding of Not At Risk was identified, and a Dietitian Referral was not ordered. The Total Malnutrition Care Score Eligible Occurrences is 2 if: The most recent Nutrition Assessment performed has a result of Not or Mildly Malnourished. And, IF: A Malnutrition Risk Screening was performed and a Malnutrition Screening Finding of At Risk was identified, or a Dietitian Referral was ordered, or a Dietitian Referral was ordered but a Nutrition Assessment was not performed.
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Measure Information

2024 Reporting Period

2025 Reporting Period

2026 Reporting Period

2028 Reporting Period

Title

Global Malnutrition Composite Score

Malnutrition Care Score

CMS eCQM ID

CMS986v2

CMS986v4

CMS986v5

CMS986v6

Short Name

GMCS

MCS

CBE ID*

3592e

Measure Steward

Academy of Nutrition and Dietetics

Description

This measure assesses the percentage of hospitalizations for adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk or for a hospital dietitian referral order, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed.

This measure assesses the percentage of hospitalizations of adults aged 65 years and older at the start of the inpatient encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.

This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients are (1) screened for malnutrition risk or for a dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.

This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients (1) are screened for malnutrition risk or for a dietitian referral order to be placed, (2) are assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN.

Measure Scoring

Continuous Variable

Measure Type

Intermediate Clinical Outcome

Intermediate Outcome

Stratification

None

Risk Adjustment

None

Rationale

The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at-risk of malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers.

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough physical assessment by registered dietitian nutritionists (RDN). The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician. The four component measures individually will only provide a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care.

Implementation of this measure supports timely nursing malnutrition risk screening and hand off to RDNs for appropriate nutritional assessment for patients at-risk of malnutrition during the current hospitalization. For patients identified with a moderate or severe malnutrition status from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professionals and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stay, and complications, as well as improved quality of life after hospitalization.

The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017).

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutritional status utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible provider as defined by CMS. The four measure observations individually will only provide a fraction of the necessary information on quality of care for patients at risk for or with malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care.

Implementation of this measure supports timely malnutrition risk screening and hand off to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with a moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of malnourished patients and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram, 2017).

Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) (Hudson, Chittams, Griffith, & Compher, 2018 and Mosquera et al., 2016) and significantly more patients with malnutrition have a LOS of greater than 7 days when compared to their well-nourished counterparts. Additionally, both higher rates of 30-day readmission and a significantly higher likelihood of 30-day readmission are observed in these patients (Mogensen et al., 2019; Hiller, Shaw, & Fabri, 2016; Mosquera et al., 2016). Lastly, hospitalized adults with malnutrition have an increased likelihood of death within 90 days of discharge (Hiller, Shaw, & Fabri, 2016). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes.

The components of this measure are supported by clinical guidance that recommends (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017).

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score.

High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of patients with malnutrition and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling demonstrates benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram et al., 2016).

Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) and a significantly higher likelihood of 30-day readmission when compared to their well-nourished counterparts (Lengfelder et al., 2022). Furthermore, hospitalized adults with malnutrition have an increased likelihood of all-cause mortality within 2 years of diagnosis (Trollebø et al., 2024) and an increase in in-hospital death when compared to patients without a diagnosis of malnutrition (Compher et al., 2024). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes.

The components of this measure are supported by clinical guidance which recommend (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; and (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Swan et al., 2019).

The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score.

High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that malnutrition pathways, which include a standardized protocol for screening, assessment, diagnosis, and care planning results in improved patient outcomes for malnourished patients (Pacetti et al., 2025).

Clinical Recommendation Statement

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (A.S.P.E.N., 2011).

This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk of malnutrition is the first step in nutrition care as nutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk.

Nutrition assessment is suggested for all patients who are identified to be at malnutrition risk by nutrition screening. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality.

Nutrition support intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition support intervention in patients identified assessment as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.

This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk.

Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality.

Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plants in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.

Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions.

American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller et al., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care, as malnutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk.

Additionally, the Academy of Nutrition and Dietetics-ASPEN Indicators of Malnutrition (AAIM) provides a framework with significant validity in diagnosing malnutrition in hospitalized patients and supporting evidence that suggests that malnourished patients have more complications, longer hospitalizations, greater incidence of 30-day readmission, and higher incidence of mortality than patients with optimal nutrition status (Compher et al., 2024; Jimenez et al., 2024).

Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications are reduced with increased nutrition support interventions.

Improvement Notation

Higher score indicates better quality of care

Higher score indicates better quality of care.

Increased score indicates improvement

Definition

Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from the nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening is performed by a nursing professional, Registered Dietitian (RD), or Registered Dietitian Nutritionist (RDN).

Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN.

Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s). For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician/eligible clinician based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery.

Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations and interventions that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, and is documented by the RD or RDN.

Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines.

Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery.

Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.

Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines.

Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery.

Malnutrition Risk Screening - The process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state, and federal guidelines.

Nutrition Assessment - A systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status, related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by an RD or RDN.

Malnutrition Diagnosis - A documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery.

Nutrition Care Plan - A documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population-Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN.

Guidance

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater.

Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed.

Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed from a "Malnutrition Screening At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization.

For Component Measure 1 and Component Measure 2, only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment".

Component Measure 3: Inpatient hospitalizations for patients with a current documented "Malnutrition Diagnosis" as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current "Nutrition Assessment Status Severely Malnourished".

Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current “Nutrition Assessment Status Severely Malnourished”.

"Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations

-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4.

-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.

"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations:

-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators.

-For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances:

-If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1.

-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2.

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:

-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed.

-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed.

-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.

-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours among individuals 65 years of age and older at the start of the inpatient encounter.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially.

This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Initial Population

Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter

Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter.

Eligible encounters during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter

Eligible encounters that end during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter

Measure Population

Equals Initial Population

Measure Population Exclusion

None

Encounters with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter

Encounters for patients with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter

Measure Observation

This is a continuous variable measure. There are six measure observations for this measure.

This measure is constructed of four clinically eligible components aggregated as an arithmetic average of eligible hospitalizations. A single measure population is used to calculate the "TotalMalnutritionComponentsScore" and "TotalMalnutritionCompositeScore as Percentage". The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater.

"Measure Observation 1" = "Encounters with Malnutrition Risk Screening and Identified Result"

"Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed with a current identified "Malnutrition Screening Not At Risk Result" or current "Malnutrition Screening At Risk Result".

"Measure Observation 2" = "Encounter with Nutrition Assessment and Identified Status"

"Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed with a current identified "Nutrition Assessment Status Not or Mildly Malnourished", "Nutrition Assessment Status Moderately Malnourished", or "Nutrition Assessment Status Severely Malnourished".

"Measure Observation 3" = "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies hospital encounters where a current "Malnutrition Diagnosis" was documented.

“Measure Observation 4” = “Encounters with Nutrition Care Plan”

"Measure Observation 4" identifies hospital encounters where a current "Nutrition Care Plan" was performed.

"Population 5 Measure Observation TotalMalnutritionComponentsScore" = ("Measure Observation 1" + "Measure Observation 2" + "Measure Observation 3" + "Measure Observation 4")

"Population 5 Measure Observation "TotalMalnutritionComponentsScore" Calculations

-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4.

-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.

"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" = 100 * ("TotalMalnutritionComponentsScore" divided by "TotalMalnutritionCompositeScore Eligible Denominators").

Population 6 Measure Observation "TotalMalnutritionCompositeScore as Percentage" Calculations:

-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances:

-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the “TotalMalnutritionCompositeScore Eligible Denominators” are 2.

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:

-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed.

-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed.

-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.

-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

There are six measure observations for this measure.

Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Hospital Dietitian Referral.

"Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Hospital Dietitian Referral"

"Measure Observation 1" identifies hospital encounters where a "Malnutrition Risk Screening" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies a hospitalization where there is a Hospital Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not.

Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization.

"Measure Observation 2" is "Encounter with Nutrition Assessment and Identified Status"

"Measure Observation 2" identifies hospital encounters where a "Nutrition Assessment" was performed or authored during the hospitalization (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished".

Component Measure 3: Inpatient hospitalizations for patients with a documented "Malnutrition Diagnosis" as a result of a "Nutrition Assessment Status Finding of Moderately Malnourished" OR "Nutrition Assessment Status Finding of Severely Malnourished".

"Measure Observation 3" is "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies hospital encounters where a "Malnutrition Diagnosis" was active during the hospitalization (including preceding observation or emergency department encounters).

Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Finding of Moderately Malnourished" OR current “Nutrition Assessment Status Finding of Severely Malnourished”.

“Measure Observation 4” is “Encounters with Nutrition Care Plan”

"Measure Observation 4" identifies hospital encounters where a "Nutrition Care Plan" was performed or authored during the hospitalization (including preceding observation or emergency department encounters).

"Population 5 Measure Observation Total Malnutrition Components Score" Calculations

-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4.

"Population 5 Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4")

"Population 6 Measure Observation Total Malnutrition Composite Score as Percentage" Calculations:

-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences.

"Population 6 Measure Observation Total Malnutrition Composite Score as Percentage" is 100 multiplied by ("Total Malnutrition Components Score" divided by "Total Malnutrition Composite Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent.

"Total Malnutrition Composite Score Eligible Occurrences" is always 4 except in the following instances:

-The "Total Malnutrition Composite Score Eligible Occurrences" is 1 if

---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered.

- The "Total Malnutrition Composite Score Eligible Occurrences" are 2

---If a "Nutrition Assessment" was performed and a "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished" was identified

--- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified AND "Hospital Dietitian Referral" was ordered OR a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed

-For the reporting facility, the Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.

-For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Composite Score as Percentage" across all eligible hospitalizations during the measurement period.

Component Measure 1: Eligible encounters for patients with a current "Malnutrition Risk Screening" performed by an eligible healthcare clinician or a Dietitian Referral.

"Measure Observation 1" is "Encounters with Malnutrition Risk Screening and Identified Result or a Dietitian Referral"

"Measure Observation 1" identifies eligible encounters where a "Malnutrition Risk Screening" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Malnutrition Screening Finding of Not At Risk Result" or "Malnutrition Screening Finding of At Risk Result". It also identifies an eligible encounter where there is a Dietitian Referral, whether there is a "Malnutrition Risk Screening" performed or not.

Component Measure 2: Eligible encounters for patients with a documented "Nutrition Assessment" performed by an RD/RDN, after a "Malnutrition Screening Finding of At Risk Result" or a "Dietitian Referral" order from a physician or eligible clinician during the current encounter.

"Measure Observation 2" is "Encounter With Most Recent Nutrition Assessment And Identified Status"

"Measure Observation 2" identifies eligible encounters where a "Nutrition Assessment" was performed or authored during the encounter (including preceding observation or emergency department encounters) with an identified "Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished", "Nutrition Assessment Status Finding of Moderately Malnourished", or "Nutrition Assessment Status Finding of Severely Malnourished".

Component Measure 3: Eligible encounters for patients with a documented "Malnutrition Diagnosis" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or "Nutrition Assessment Status Finding of Severely Malnourished".

"Measure Observation 3" is "Encounters with Malnutrition Diagnosis"

"Measure Observation 3" identifies eligible encounters where a "Malnutrition Diagnosis" was active during the encounter (including preceding observation or emergency department encounters).

Component Measure 4: Eligible encounters for patients with a documented "Nutrition Care Plan" based on the most recent finding of "Nutrition Assessment Status Finding of Moderately Malnourished" or “Nutrition Assessment Status Finding of Severely Malnourished”.

“Measure Observation 4” is “Encounters with Nutrition Care Plan”

"Measure Observation 4" identifies eligible encounters where a "Nutrition Care Plan" was performed or authored during the encounter (including preceding observation or emergency department encounters).

Population 5 "Measure Observation Total Malnutrition Components Score" Calculations -For each eligible encounter, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4.

Population 5 "Measure Observation Total Malnutrition Components Score" is ("Measure Observation 1" plus "Measure Observation 2" plus "Measure Observation 3" plus "Measure Observation 4") Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" Calculations: -For each eligible encounter, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences.

Population 6 "Measure Observation Total Malnutrition Care Score as Percentage" is 100 multiplied by ("Measure Observation Total Malnutrition Components Score" divided by "Total Malnutrition Care Score Eligible Occurrences"). Possible values may be 0, 50, 75, or 100 percent.

"Total Malnutrition Care Score Eligible Occurrences" is always 4 except in the following instances:

-The "Total Malnutrition Care Score Eligible Occurrences" is 1 if

---A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was not ordered.

- The "Total Malnutrition Care Score Eligible Occurrences" is 2

---If the most recent "Nutrition Assessment" performed has a result of "Nutrition Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished".

--- A "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of Not At Risk Result" was identified and "Dietitian Referral" was ordered or a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Finding of At Risk Result" was identified but the “Nutrition Assessment” was not performed.

Component Measure 1: Eligible encounters for patients with a current Malnutrition Risk Screening performed by an eligible healthcare clinician or with a Dietitian Referral. Measure Observation 1 is Encounters with Malnutrition Risk Screening or with a Dietitian Referral. Measure Observation 1 identifies eligible encounters where a Malnutrition Risk Screening was performed during the encounter (including associated observation or emergency department encounters) with an identified Malnutrition Screening Finding of Not At Risk or At Risk Result. It also identifies an eligible encounter where there is a Dietitian Referral, whether there is a Malnutrition Risk Screening performed or not.

Component Measure 2: Eligible encounters for patients with a documented Nutrition Assessment performed by an RD/RDN, and with a Malnutrition Screening Finding of At Risk Result or a Dietitian Referral order from a physician or eligible clinician during the current encounter. Measure Observation 2 includes Encounters with Most Recent Nutrition Assessment and Identified Status if the encounter also contains Completed Malnutrition Risk Screening or Dietitian Referral. Measure Observation 2 identifies eligible encounters in which a malnutrition risk screening with an At Risk Result or a dietitian referral was completed during the encounter (or associated observation or emergency department encounters) and a Nutrition Assessment was subsequently completed with an identified Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished, Nutrition Assessment Status Finding of Moderately Malnourished, or Nutrition Assessment Status Finding of Severely Malnourished.

Component Measure 3: Eligible encounters for patients with a documented Malnutrition Diagnosis based on the most recent Nutrition Assessment Finding of Moderately Malnourished or Severely Malnourished. Measure Observation 3 includes encounters with the most recent Nutrition Assessment and Identified Status of Moderately Malnourished or Severely Malnourished, that also identified an active medical malnutrition diagnosis during the encounter (including preceding observation or emergency department encounters) and a Malnutrition Risk Screening At Risk Result or with a Dietitian Referral.

Component Measure 4: Eligible encounters for patients with a documented Nutrition Care Plan based on the most recent Nutrition Assessment Finding of Moderately Malnourished or Severely Malnourished. Measure Observation 4 identifies encounters with the most recent Nutrition Assessment and Identified Status of Moderately Malnourished or Severely Malnourished, that also include a documented Nutrition Care Plan and a Malnutrition Risk Screening At Risk Result or with a Dietitian Referral. Measure Observation 4 identifies eligible encounters where a Nutrition Care Plan was performed during the encounter (including preceding observation or emergency department encounters).

Population 5 Measure Observation Total Malnutrition Components Score Calculations: For each eligible encounter, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4. Possible values may be 0, 1, 2, 3, or 4. Population 5 Measure Observation Total Malnutrition Components Score is (Measure Observation 1 plus Measure Observation 2 plus Measure Observation 3 plus Measure Observation 4).

Population 6 Measure Observation Total Malnutrition Care Score as Percentage Calculations: For each eligible encounter, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible occurrences. Population 6 Measure Observation Total Malnutrition Care Score as Percentage is 100 multiplied by (Measure Observation Total Malnutrition Components Score divided by Total Malnutrition Care Score Eligible Occurrences). Possible values may be 0, 50, 75, or 100 percent. Total Malnutrition Care Score Eligible Occurrences is always 4 except in the following instances:

The Total Malnutrition Care Score Eligible Occurrences is 1 if:

A Malnutrition Risk Screening was performed, and a Malnutrition Screening Finding of Not At Risk was identified, and a Dietitian Referral was not ordered.

The Total Malnutrition Care Score Eligible Occurrences is 2 if:

The most recent Nutrition Assessment performed has a result of Not or Mildly Malnourished.
And, IF:
A Malnutrition Risk Screening was performed and a Malnutrition Screening Finding of At Risk was identified, or a Dietitian Referral was ordered, or a Dietitian Referral was ordered but a Nutrition Assessment was not performed.

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