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Malnutrition Care Score

Compare Versions of: "Malnutrition Care Score"

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Compare 2026 version to

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Measure Information 2026 Reporting Period
Title Malnutrition Care Score
CMS eCQM ID CMS986v5
Short Name

MCS

CBE ID* 3592e
Measure Steward Academy of Nutrition and Dietetics
Description

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...

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Measure Scoring Continuous Variable
Measure Type Intermediate Outcome
Stratification

None

Risk Adjustment

None

Rationale

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...

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Clinical Recommendation Statement

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).

...

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Improvement Notation

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 nutrition interventions. For the inpatient or acute care setting,...

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Guidance

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...

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Initial Population

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

Measure Population

Equals Initial Population

Measure Population Exclusion

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

Next Version No Version Available
Previous Version

Header

TRN

Measure Section

Source of Change

Updated 'eCQM Identifier (Measure Authoring Tool)' field to 'CMS ID' based on tooling update.

CMS ID

Standards/Technical Update

Updated the eCQM version number.

eCQM Version Number

Annual Update

Updated measurement period to reflect exact dates of reporting.

Measurement Period

Standards/Technical Update

Updated copyright.

Copyright

Annual Update

Updated disclaimer.

Disclaimer

Annual Update

Updated measure type from 'Intermediate Clinical Outcome' to 'Intermediate Outcome' based on new tooling requirements.

Measure Type

Annual Update

Updated Improvement Notation field to read 'Increased score indicates improvement' based on tooling update to promote alignment across measures.

Improvement Notation

Standards/Technical Update

Added Measure Population Exclusions for patients receiving or discharged to hospice care to align with measure intent.

Definition

Expert Work Group Review

Added Measure Population Exclusions for patients receiving or discharged to hospice care to align with measure intent.

Measure Population Exclusions

Expert Work Group Review

Updated the definitions for Measure Observations 2, 3, and 4 and for 'eligible occurrences' by adding 'most recent' before references to 'nutrition assessment' to emphasize the prioritization of the most recent results, aligning with malnutrition care recommendations.

Measure Observations

Measure Lead

Updated references and measure header to reflect current evidence and new or updated literature.

Multiple Sections

Measure Lead

Updated grammar, wording, and/or formatting to improve readability and consistency.

Multiple Sections

Annual Update

Updated language throughout the header to consistently use 'eligible encounter' instead of 'eligible hospitalization,' 'inpatient hospitalizations,' 'hospital encounters,' or 'inpatient encounter'.

Multiple Sections

Measure Lead

Updated definition names to consistently reference 'encounter'.

Multiple Sections

Measure Lead

Removed the 'hospital' prefix from when referring to 'dietitian referral' to better reflect measure intent.

Multiple Sections

Measure Lead

Changed measure name from 'Global Malnutrition Composite Score' to 'Malnutrition Care Score' to better represent measure intent.

Multiple Sections

Annual Update

Updated the Initial Population age criteria from 65 years of age and older to 18 years of age and older to align with the measure's expanded age range finalized in the CMS Fiscal Year 2025 Inpatient Prospective Payment System final rule.

Multiple Sections

Measure Lead

Updated Measure Set section to 'None' in alignment with measure header standards.

Measure Set

Measure Lead

Logic

TRN

Measure Section

Source of Change

Updated Initial Population measure logic to include only encounters that end during the measurement period to align with other hospital eCQMs.

Initial Population

ONC Project Tracking System (JIRA): CQM-6409

Updated definition names to consistently reference 'encounter'.

Measure Observations

Measure Lead

Updated intervention logic and removed 'Hospital' from measure logic definition, 'Encounter with Hospital Dietitian Referral,' to simplify logic and better reflect measure intent.

Measure Observations

Measure Lead

Added Measure Population Exclusions for patients receiving or discharged to hospice care to align with measure intent, reflected by the 'Encounter with Hospice During Eligible Encounter' and 'Encounter with Discharge for Hospice Care' definitions.

Measure Population Exclusions

Expert Work Group Review

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Definitions

Annual Update

Updated the Initial Population age criteria from 65 years of age and older to 18 years of age and older to align with the measure's expanded age range finalized in the CMS Fiscal Year 2025 Inpatient Prospective Payment System final rule.

Definitions

Measure Lead

Added Measure Population Exclusions for patients receiving and discharged to hospice care to align with measure intent, reflected by the 'Encounter with Hospice During Eligible Encounter' and 'Encounter with Discharge for Hospice Care' definitions.

Definitions

Expert Work Group Review

Added the definition 'Nutrition Assessment Performed' to simplify logic for assessment prioritization and align with measure intent.

Definitions

Measure Lead

Updated the CQL library name from 'CMS986-v4-0-000-QDM-5-6.cql' to 'CMS986MalnutritionScore-5.4.000.cql' based on recommendation by technical experts.

Definitions

Standards/Technical Update

Removed 'Hospital' from measure logic definition 'Hospital Dietitian Referral' to simplify logic and better reflect measure intent.

Definitions

Measure Lead

Updated definition names to consistently reference 'encounter'.

Definitions

Measure Lead

Updated logic definitions used for Measure Observations to reference 'Measure Population' instead of 'Initial Population' to better align with the process for computing a continuous variable measure.

Definitions

Measure Lead

Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

Definitions

Standards/Technical Update

Updated measure logic by eliminating if/then redundant logic directions to simplify logic and align with malnutrition care recommendations.

Functions

Measure Lead

Updated the version number of the Global Shared Library to v9.0.000 and the library name from 'MATGlobalCommonFunctionsQDM' to 'CQMCommonQDM'.

Functions

Annual Update

Changed several measure definition names containing 'malnutrition composite score' to instead reference 'malnutrition care score' to better represent logic intent.

Multiple Sections

Annual Update

Added 'Most Recent' to measure logic definitions and functions to reflect the prioritization of the most recent assessment results and to align with measure intent.

Multiple Sections

Measure Lead

Removed the definitions, 'Encounter with Nutrition Assessment Status Finding of Moderately Malnourished' and 'Encounter with Nutrition Assessment Status Finding of Severely Malnourished,' to simplify logic and align with measure intent.

Multiple Sections

Measure Lead

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

TRN

Measure Section

Source of Change

Replaced value set used for Sex Supplemental Data Element (SDE) ONC Administrative Sex (2.16.840.1.113762.1.4.1) with value set Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121) based on updated standards.

Terminology

Standards/Technical Update

Value set (2.16.840.1.113762.1.4.1095.91): Renamed to Dietitian Referral based on change in measure requirements/measure specification.

Terminology

Measure Lead

Value set Dietitian Referral (2.16.840.1.113762.1.4.1095.91): Added 1 SNOMED CT code (103699006) based on review by technical experts, SMEs, and/or public feedback. Added 1 SNOMED CT code (408285001) based on change in measure requirements/measure specification.

Terminology

Measure Lead

Added value set Hospice Care Referral or Admission (2.16.840.1.113762.1.4.1116.365) based on review by technical experts, SMEs, and/or public feedback.

Terminology

Measure Lead

Added value set Hospice Status (2.16.840.1.113762.1.4.1095.101) based on review by technical experts, SMEs, and/or public feedback.

Terminology

Measure Lead

Value set Malnutrition Diagnosis (2.16.840.1.113762.1.4.1095.55): Added 11 ICD-10-CM codes (O25.10, O25.11, O25.12, O25.13, O25.2, O25.3, E40, E41, E42, E64.0, E45) based on change in measure requirements/measure specification. Added 1 SNOMED CT code (432788009) based on change in measure requirements/measure specification.

Terminology

Measure Lead

Value set Malnutrition Screening Finding of At Risk Result (2.16.840.1.113762.1.4.1095.89): Deleted 1 SNOMED CT code (704358009) based on terminology update.

Terminology

Annual Update

Value set Nutrition Assessment Status Finding of Severely Malnourished (2.16.840.1.113762.1.4.1095.43): Added 1 SNOMED CT code (432788009) based on change in measure requirements/measure specification.

Terminology

Measure Lead

Last Updated: May 06, 2025