Nutritional Diagnosis Grid - Alabama Medicaid Agency

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Impact > 12 months Adult For critically ill patients. May use up to 4 weeks immediately post-hospital discharge: Cardiac/circulatory (441.3, 441.5, 441.1, 402.01, 402.11, 402.91, 429.4, 410.00-410.91, 403.0, 403.1, 403.9, 404.3, 404.93, 415.0, 425, 426.0, 426.1); Respiratory (480, 480.1, 480.2, 481, 482, 483, 486, 492.8, 493, 518.0, 518.4, 518.5, 518.8, 518.82); Neuro (430, 431); Trauma/surgical (879.88, 829.0, 949.3, 949.4, 949.5, 948.0-948.9, 564.2, 579.3, 042, 998.83); GI (558.9, 579.3, 579.8, 579.9, 579.0, 799.4, 261, 263.0, 263.1, 263.8, 563.9, 199.1, 269.8, 269.9); Renal (584.9, 585, 586, 581.9, 583.9, 599.6, 753.19, 591, 753, 486, 518.5, 518.82, 518.81); Pressure sores (707.0); Burns (940-949); HIV or AIDS (042); COPD (492.8); Cardiomyopathy (425.4); Cirrhosis/Liver disease (571.3, 571.4, 571.5, 571.9, 573.3, 573.9, 751.3) Impact 1.5 > 2 Adult Impact Glutamine >12 months Adult Impact with Fiber > 2 Adult Isocal > 12 months Adult Critically ill patients who are fluid restricted or have high calorie needs: fluid restriction (CHF 428.9, Neurosurgery/Cerebral edema 348.5 ); high calorie requirements (Cancer 199.1, Cachexia 799.4, Malnutrition 261, COPD 492.8, Cardiomyopathy 425.4) Cardiac/circulatory (441.3, 441.5, 441.1, 402.01, 402.11, 402.91, 429.4, 410.00-410.91, 403.0, 403.1, 403.9, 404.3, , 404.93, 415.0, 425, 426.0, 426.1); Respiratory (480, 480.1, 480.2, 481, 482, 483, 486, 492.8, 493, 518.0, 518.4, 518.5, 518.8, 518.82); Neuro (430, 431); Trauma/surgical (879.88, 829.0, 949.3, 949.4, 949.5, 948.0-948.9, 564.2, 579.3, 998.83); Renal (584.9, 585. 586, 581.9, 583.9, 599.6, 753.19, 591, 753, 486, 518.5, 518.82, 518.81); Pressure sores (707.0); Burns (940-949); Non-healing surgical wound (998.83); Coma (780.01, 780.09); Cirrhosis/Liver disease (571.3, 571.4, 571.5, 571.9, 573.3, 573.9, 751.3) GI impairment: short bowel syndrome: 579.3, IBD 558.9, malabsorption syndrome: 579.9, cow’s milk enteropathy/sensitivity: 579.8, Crohn’s disease: 555.0, 555.1, 555.2, 555.9, GI fistula, intractable diarrhea: 787.91, 564.5; AIDS-related GI disorders: 042, celiac disease: 579.0, cystic fibrosis: 277.0, chronic diarrhea: 787.91, pancreatic disorders: 577.9 Pre-and post-surgery, up to 4 weeks (564.2, 564.4, 579.3, 998.83); Trauma (925-929.9, 829.0, 829.1, 861.3, 862.3, 863.1, 863.3, 863.5, 863.9, 867.1, 867.7, 867.9, 869.1, 873.7, 874.5, 875.1, 876.1, 879.3, 879.5, 879.8, 879.9, 890.1, 891.1, 894.1, 890.1); Cancer (199.1); Burns (940.0-949.5); Pressure ulcers (707.0); Infections (001.0-009.3, 010.0-014.8, 020.0-0279.9, 030.0-041.9, 042, 045.0-049.9, 070.0, 070.2, 070.4, 070.41, 070.42, 070.43, 070.44, 070.49) Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS (341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Senile dementia (290.0); Malnutrition (261); Post-op feeding, within 30 days of surgery (579.3) Isosource Standard/ Isosource 1.5 ≥ 12 Adult Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS ( 341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Senile dementia (290.0); Malnutrition (261); Post-op feeding, within 30 days of surgery (579.3); CF (277.0) 6 10/1/11
Isosource Protein/ Isosource HN ≥ 12 Adult Isosource Energy ≥ 12 Adult Isosource Energy Fibre ≥ 12 Adult Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbular palsy (335.23); Encephalopathy (348.3); Senile Dementia (290.0); Malnutrition (261);Post-op feeding, within 30 days of surgery (579.3); Burns (940-949); Wounds (707.0, 879.8, 998.83); Malnutrition (799.4, 199.1, 759.3, 263.0, 263.9, 263.8, 783.4); COPD (492.8) Cardiomyopathy (425.4) Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Post-op feeding, within 30 days of surgery (579.3); Burns (940-949); Wounds (707.0, 879.8, 998.83); Malnutrition (799.4, 199.1, 759.3, 263.0, 263.9, 263.8, 783.4, 261); CHF (428.0); Fluid overload (276.6); Renal failure (584.9, 586, 585); COPD (492.8); Cardiomyopathy (425.4) Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Post-op feeding, within 30 days of surgery (579.3); Burns (940-949); Wounds (707.0, 879.8, 998.83); Malnutrition (799.4, 199.1, 759.3, 263.0, 263.9, 263.8, 783.4, 261); CHF (428.0); COPD (492.8); Fluid overload (276.6); Renal failure (584.9, 586, 585); Cardiomyopathy (425.4) Isosource MIX ≥ 12 Adult Inadequate oral intake, voluntary (anorexia 783.0) and involuntary (barriers to normal ingestion): Dysphagia (787.2); Malignancy of lip, oral cavity & pharyngeal cavity (140.0-149.9); Alzheimer’s disease (331.0); Huntington’s chorea (334.0); Jakob-Creutzfeldt disease (046.1); MS (340); Other demyelinating disease of CNS (341.8, 341.9); Pick’s disease (331.0); Profound mental retardation (318.2); Coma (780.01, 780.09); Persistent vegetative state (780.03); Leukodystrophy (330.0); Cerebral Lipidosis (330.1); Other specific cerebral degeneration in childhood (Rett’s syndrome) (330.8); Cerebral degeneration in generalized lipidoses (330.2, with underlying disease code); Cerebral degeneration of childhood in other diseases classified elsewhere (330.3, with underlying disease code); Parkinson’s disease (332.0, 332.1); Supranuclear Palsy (333.0); ALS (335.20); Motor neuron disease (335.2); Progressive muscular atrophy (335.21); Progressive bulbar palsy (335.22); Psuedobulbar palsy (335.23); Encephalopathy (348.3); Post-op feeding, within 30 days of surgery (579.3); Burns (940-949); Wounds (707.0, 879.8, 998.83); Malnutrition (799.4, 199.1, 759.3, 263.0, 263.9, 263.8, 783.4, 261); CHF(428.0); COPD (492.8); Fluid overload (276.6); Renal failure (584.9, 586, 585); Cardiomyopathy (425.4) 7 10/1/11
Page 1 and 2: NUTRITIONAL PRODUCT GRID PRODUCT PE
Page 3 and 4: Diabetisource AC ≥ 10 Adult Duoca
Page 5: FiberSource HN > 12 months Adult Co
Page 9 and 10: Kindercal TF/ Kindercal TF w/Fiber
Page 11 and 12: Nutren 1.0 with Fiber ≥ 10 Adult
Page 13 and 14: Optimental > 10 Adult Metabolically
Page 15 and 16: Peptamen with Prebio ≥ 10 Adult P
Page 17 and 18: Pulmocare > 12 months Adult Pulmona
Page 19: XLYS, XTRP Analog 1-10 N/A Glutaric

Nutritional Diagnosis Grid - Alabama Medicaid Agency

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