Malnutrition Care Score

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.

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This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.
THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
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For the reporting facility, the Aggregate Operator 'Count' includes the number of eligible encounters during the measurement period. For the reporting facility, the Aggregate Operator 'Average' averages the performance of each "Total Malnutrition Care Score as Percentage" across all eligible encounters during the measurement period.

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).

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.

Increased score indicates improvement

Reference Type: Citation

Reference Text: 
Compher, C., Jensen, G. L., Malone, A., Morgan, S., Becker, S., Cresta, L., Paul, A. M., & Steiber, A. (2024). Systematic review of content validity and meta-analysis of predictive validity for clinical outcomes associated with malnutrition identified by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Indicators of Malnutrition. Journal of the Academy of Nutrition and Dietetics, 125(5), 600-602. https://doi.org/10.1016/j.jand.2024.02.002

Reference Type: Citation

Reference Text: 
Jimenez, E. Y., Lamers-Johnson, E., Long, J. M., Woodcock, L., Bliss, C., & Steiber, A. L. (2024). Predictive validity of the Academy of Nutrition and Dietetics/American Society for Parental Nutrition indicators to diagnose malnutrition and the screening tool for risk on nutritional status and growth among hospitalized children relative to medical outcomes. The Journal of Pediatrics, 276, 114288. https://doi.org/10.1016/j.jpeds.2024.114288

Reference Type: Citation

Reference Text: 
Lengfelder, L., Mahlke, S., Moore, L., Zhang, X., Williams, G., & Lee, J. (2022). Prevalence and impact of malnutrition on length of stay, readmission, and discharge destination. Journal of Parenteral and Enteral Nutrition, 46(6). https://doi.org/10.1002/jpen.2322

Reference Type: Citation

Reference Text: 
Mogensen, K.M., Malone, A., Becker, P., Cutrell, S., Frank, L., Gonzales, K., Hudson, L., Miller, S., & Guenter, P. (2019). Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: Usability and association with outcomes. Nutrition in Clinical Practice, 34(5), 657–665. https://doi.org/10.1002/ncp.10310

Reference Type: Citation

Reference Text: 
Mueller, C., Compher, C., Druyan, M. E., & the ASPEN Board of Directors. (2011). ASPEN clinical guidelines on nutrition screening, assessment, and intervention in adults. Journal of Parenteral and Enteral Nutrition, 35(1), 16-24. https://doi.org/10.1177/0148607110389335

Reference Type: Citation

Reference Text: 
Pacetti, E. J., McMurray, D., & Baca, J. (2025). Quality improvement in acute care malnutrition: Impact on payment and patient outcomes. Journal of the Academy of Nutrition and Dietetics, 125(9), S24–S35. https://doi.org/10.1016/j.jand.2025.05.018

Reference Type: Citation

Reference Text: 
Swan, W. I., Pertel, D. G., Hotson, B., Lloyd, L., Orrevall, Y., Trostler, N., Vivanti, A., Howarter, K. B., & Papoutsakis, C. (2019). Nutrition care process (NCP) update part 2: Developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. Journal of the Academy of Nutrition and Dietetics, 119(5), 840–855. https://doi.org/10.1016/j.jand.2018.10.025

Reference Type: Citation

Reference Text: 
Trollebø, M. A., Tangvik, R. J., Skeie, E., Grønning, M. K., Nygård, O., Eagan, T. M. L., & Dierkes, J. (2024). Malnutrition as a prognostic factor for 2‐year mortality in hospitalized patients in Norway: A matched cohort study. Journal of Parenteral and Enteral Nutrition, 48(3), 308–317. https://doi.org/10.1002/jpen.2619

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.

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.

TBD

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

Equals Initial Population

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

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.
 

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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