Selected Topics from the 2015 OIG WORK PLAN: Payments for Patients Diagnosed with Kwashiorkor

Selected Topics from the 2015 OIG WORK PLAN: Payments for Patients Diagnosed with Kwashiorkor

by Christopher Richards, RHIA, CCS

This series of posts will highlight potential provider vulnerabilities with respect to the OIG 2015 work plan. Our sister company, Barry Libman Inc., is available to assist you with any areas where you feel you might have potential exposure. Certainly, everyone is in full agreement that a good compliance plan strives to identify concerns before the OIG does.


Hospitals—Billing and Payments – Payments for patients diagnosed with kwashiorkor

“We will review Medicare payments made to hospitals for claims that include a diagnosis of kwashiorkor to determine whether the diagnosis is adequately supported by documentation in the medical record. To be processed correctly and promptly, a bill must be completed accurately.

“A diagnosis of kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare. Kwashiorkor is a form of severe protein malnutrition that generally affects children living in tropical and subtropical parts of the world during periods of famine or insufficient food supply. It is typically not found in the United States. Prior OIG reviews have identified inappropriate payments to hospitals for claims with a kwashiorkor diagnosis.”


ICD-9-CM code for kwashiorkor is 260 and is a major complication/comorbidity (MCC).

In the ICD-9-CM index, there is only one way to get to the code for Kwashiorkor without specific documentation of Kwashiorkor and that is:

Protein 260

Protein-calorie malnutrition is coded 263.9 – complication/comorbidity (CC)
Severe malnutrition, not otherwise specified (NOS) is coded 261 (MCC)
Moderate protein malnutrition is coded 263.0 (non-CC)
Other protein malnutrition is coded 263.8 (CC)
Severe protein-calorie malnutrition is coded 262 (MCC)

So clearly this can be confusing and therefore it would be our recommendation to query the physician anytime the index leads you to code 260.  This is the code the OIG is looking for and there may be far better ways to document a patient’s nutrition status without assigning the “red flag” code 260.

The American Hospital Association’s Coding Clinic 3rd Quarter 2009 further states that “260 – Kwashiorkor is not an appropriate code when the provider did not specifically document this condition”.

Additionally, this would be a good time to bring together the nutrition team to review documentation improvement strategies to capture common nutritional deficiencies.

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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