by Rose T. Dunn, MBA, RHIA, CPA, FACHE
A recent article in Becker’s Hospital CFO Report entitled “Hospitals Overbilled Medicare $1B by Upcoding Claims, Inspector General Finds” caught my attention.
The specific finding by OIG is that assignment of diagnosis codes for severe malnutrition to inpatient hospital claims (when they should have used codes for other forms of malnutrition or no malnutrition code at all) resulted in significant over-billing. The OIG is calling for the money to be returned.
My recommendation is to focus internal auditing to identify variances in the frequency of conditions appearing in one or more provider’s case mix. What should you look for when faced with documentation and coding of malnutrition?
Malnutrition is one of the most over-documented HCC conditions. How does this happen? Sometimes over-documentation results from overzealous clinical documentation integrity specialists. However, if a provider is sharing in HCC payments, there may be an incentive on the provider’s part to over-document conditions that lead to another HCC.
Those working in a risk-adjusted environment need to talk to their providers when they see what might be indications of malnutrition. Just leaving a query can lead to the provider wanting to get rid of another piece of paper or email in their inbox—so, they “agree” rather than spend time to “reject” and give a reason. This is the ideal time to talk with your provider about documentation integrity. Talking directly to the provider has benefits for both parties:
- the provider can explain why the patient’s situation does not qualify for a diagnosis of malnutrition, and
- for the coding or clinical documentation specialist, it becomes a learning opportunity.
According to the CDI Pocket Guide – Online Edition from authors Pinson and Tang:
Diagnostic Criteria: Traditionally, the diagnosis of malnutrition depended on a subjective clinical judgment taking into account the number and severity of physical and clinical findings, such as chronic disease (cancer, end-stage disease, AIDS, alcoholism), physical findings (cachexia, muscle/adipose wasting), body mass composition (low BMI, low body weight, unintended weight loss), and serum markers (low albumin, prealbumin, transferrin, retinal-binding protein)—although serum markers are often unreliable indicators of malnutrition.
ASPEN Malnutrition Consensus Statement from the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) has become a widely-adopted nutritional diagnostic standard in the U.S. since its publication in 2012.
The ASPEN diagnosis of malnutrition is based on the presence of at least two of six characteristics distinguishing non-severe and severe malnutrition in three different clinical contexts. The 6 CHARACTERISTICS are:
- Insufficient energy intake
- Weight loss
- Loss of muscle mass
- Loss of subcutaneous fat
- Localized or generalized fluid accumulation (edema) that can mask weight loss
- Diminished functional status as measured by calibrated hand grip strength device
Note: #2 (weight loss) and #5 (edema) should be considered mutually exclusive. To apply the edema characteristic, it must “mask weight loss”; therefore, if the weight loss criterion is met, it can’t be “masked” by edema.
Global Leadership Initiative on Malnutrition (GLIM): “GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report from the Global Clinical Nutrition Community” published in the January 2019 issue of the Journal of Parenteral and Enteral Nutrition. The purpose of GLIM is to reach a unified global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition in clinical settings. The purpose of GLIM is to reach a global consensus on the identification and endorsement of criteria for the diagnosis of malnutrition in clinical settings.
GLIM diagnostic criteria. The GLIM diagnosis of malnutrition is based on five diagnostic criteria: three phenotypic (clinical findings) and two etiologic (causes). The diagnosis of malnutrition requires at least one phenotypic criterion and one etiologic criterion.
Coding and Documentation Challenges: Under-recognition and under treatment of malnutrition, sometimes even when severe, is widespread – truly a malnutrition crisis especially for the acutely ill. These new guidelines and definitions are intended to promote correction of this wide-spread threat to health. The need for education and awareness is great.
These criteria should not be applied by checking-off a minimum number of criteria from a list. Each patient’s unique, overall clinical picture must be considered together with these criteria using good clinical judgment. Never lose sight of the whole person.
The National Council on Aging states
“people with malnutrition can be both underweight or overweight. Obese individuals can—and often do—miss out on important nutrients. Malnutrition is an imbalance of nutrients—meaning your diet may be high in calories but is low in nutrients that your body needs. Malnutrition is a significant problem across the world, including the U.S. While some of the causes may differ—lack of food, not enough of the right nutrients—too many individuals confront malnutrition:
- Muscle weakness
- Increased illness or infection
- Feeling irritable or depressed”
HCC: Auditing in the Risk Adjustment Environment
Internal HCC auditors: get the essential information you need to ensure your organization receives proper reimbursement — and that codes and claims are supported by clinical documentation.
Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn! Learn more here.