K0520: Nutritional Approaches
K0520: Nutritional Approaches
Item Rationale
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Health-related Quality of Life
Nutritional approaches that vary from the normal (e.g., mechanically altered food) or that rely on alternative methods (e.g., parenteral/IV or feeding tubes) can diminish an individual’s sense of dignity and self-worth as well as diminish pleasure from eating.
The resident’s clinical condition may potentially benefit from the various nutritional approaches included here. It is important to work with the resident and family members to establish nutritional support goals that balance the resident’s preferences and overall clinical goals.
Planning for Care
Alternative nutritional approaches should be monitored to validate effectiveness.
Care planning should include periodic reevaluation of the appropriateness of the approach.
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Steps for Assessment
Review the medical record to determine if any of the listed nutritional approaches were performed during the look-back period.
If none apply, check K0520Z. None of the above.
Coding Instructions
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Check all that apply. If none apply, check K0520Z, None of the above |
K0520A, parenteral/IV feeding.
K0520B, feeding tube – nasogastric or abdominal (PEG).
K0520C, mechanically altered diet – require change in texture of food or liquids (e.g., pureed food, thickened liquids).
K0520D, therapeutic diet (e.g., low salt, diabetic, low cholesterol).
K0520Z, none of the above.
Coding Instructions for Column 1
Check all nutritional approaches performed during the first 3 days of the SNF PPS Stay.
Coding Instructions for Column 2
Check all nutritional approaches performed prior to admission/entry or reentry to the facility and within the
7-day look-back period. Leave Column 2 blank if the resident was admitted/entered or reentered the facility more than 7 days ago.
When completing the Interim Payment Assessment (IPA), the completion of items K0520A, K0520B, and K0520Z is required.
Coding Instructions for Column 3
Check all nutritional approaches performed after admission/entry or reentry to the facility and within the 7-day look-back period.
Coding Instructions for Column 4
Check all nutritional approaches performed within the last 3 days of the SNF PPS Stay.
Coding Tips for K0520A
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K0520A includes any and all nutrition and hydration received by the nursing home resident during the observation period either at the nursing home, at the hospital as an outpatient or an inpatient, provided they were administered for nutrition or hydration. |
Parenteral/IV feeding—The following fluids may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident’s medical record according to State and Federal Regulations and/or internal facility policy:
IV fluids or hyperalimentation, including total parenteral nutrition (TPN), administered continuously or intermittently
IV fluids running at KVO (Keep Vein Open)
IV fluids contained in IV Piggybacks
Hypodermoclysis and subcutaneous ports in hydration therapy
IV fluids can be coded in K0520A if needed to prevent dehydration if the additional fluid intake is specifically needed for nutrition and hydration. Prevention of dehydration should be clinically indicated and supporting documentation should be provided in the medical record.
The following items are NOT to be coded in K0520A:
IV Medications—Code these when appropriate in O0110H, IV Medications.
IV fluids used to reconstitute and/or dilute medications for IV administration.
IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay.
IV fluids administered solely as flushes.
Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.
Enteral feeding formulas:
Should not be coded as a mechanically altered diet.
Should only be coded as K0520D, Therapeutic Diet when the enteral formula is altered to manage problematic health conditions, e.g. enteral formulas specific to residents with diabetes.
Coding Tip for K0520B
Only feeding tubes that are used to deliver nutritive substances and/or hydration during the assessment period are coded in K0520B.
Coding Tips for K0520C
Assessors should not capture a trial of a mechanically altered diet (e.g., pureed food, thickened liquids) during the observation period in K0520C, mechanically altered diet.
Coding Tips for K0520D
Therapeutic diets are not defined by the content of what is provided or when it is served, but why the diet is required. Therapeutic diets provide the corresponding treatment that addresses a particular disease or clinical condition which is manifesting an altered nutritional status by providing the specific nutritional requirements to remedy the alteration.
A nutritional supplement (house supplement or packaged) given as part of the treatment for a disease or clinical condition manifesting an altered nutrition status, does not constitute a therapeutic diet, but may be part of a therapeutic diet. Therefore, supplements (whether given with, in-between, or instead of meals) are only coded in K0520D, Therapeutic Diet when they are being administered as part of a therapeutic diet to manage problematic health conditions (e.g. supplement for protein-calorie malnutrition).
Food elimination diets related to food allergies (e.g. peanut allergy) can be coded as a therapeutic diet.
Examples
Resident H was diagnosed in the acute hospital with a soft tissue infection. A treatment regime was initiated in the acute hospital, including IV antibiotics received every 8 hours within the last 7 days. Because the resident was assessed in the acute hospital with inadequate oral fluid intake demonstrating signs and symptoms of dehydration, the acute care physician ordered that the antibiotic be reconstituted with 250 cc of normal saline rather than 100 cc, which is the minimum amount required for reconstitution. This IV antibiotic and fluid regimen continues for 7 additional days following admission to the SNF due to continued infection and decreased oral intake.
Coding: K0520A1, K0520A2, and K0520A3 would be checked. The IV medication would be coded at IV Medications item (O0110H).
Rationale: The resident’s physician in the acute care hospital ordered additional volume of dilutant for the IV medication reconstitution to address Resident H’s inadequate oral fluid intake. The treatment regime continues upon admission to the SNF to address hydration needs. There is supporting documentation that reflected an identified need for additional fluid intake for hydration.
Resident J is receiving an antibiotic in 100 cc of normal saline via IV. They have a UTI, no fever, and documented adequate fluid intake. They are placed on the nursing home’s hydration plan to ensure adequate hydration.
Coding: K0520A1 would NOT be checked. The IV medication would be coded at
IV Medications item (O0110H).
Rationale: Although the resident received the additional fluid, there is no documentation to support a need for additional fluid intake.
Resident Q will be discharged today following a 16-day stay in the nursing home. They were receiving rehabilitation services for a stroke. They have longstanding celiac disease and therefore were placed on a gluten-free diet. Because of their recent stroke, they also have documented dysphagia requiring a mechanical soft diet and honey-thick liquids to prevent aspiration and will be discharged on this same diet.
Coding: K0520C3 and K0520C4, as well as K0520D3 and K0520D4, would be checked.
Rationale: Resident Q required both a mechanically altered diet (i.e., mechanical soft diet and honey-thick liquids) and a therapeutic diet (i.e., gluten free) for their celiac disease in the last 7 days as well as at discharge.
Resident B will be discharged today after rehabilitation services for multiple fractures sustained in a car accident. Resident B has been on a regular diet during their entire stay and has not required any parenteral or enteral nutrition. During the acute hospital stay Resident B required a mechanical soft diet following the accident. The resident upgraded to a regular texture diet prior to discharge from the hospital.
Coding: K0520Z3and K0520Z4 would be checked.
Rationale: Resident B had a regular diet their entire stay and did not require any nutritional modifications.
