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Hospital Claims for Severe Malnutrition under Scrutiny

Background

In January 2018, the Office of the Inspector General (OIG) announced inclusion in its Work Plan a new project to assess the accuracy of Medicare payments for the treatment of severe malnutrition. These claims are coming under scrutiny since a diagnosis of severe malnutrition on a claim substantially increases the hospital's reimbursement from Medicare as it is classified as a major complication or comorbidity (MCC).

On July 13, 2020, the Office of the OIG under the Department of Health and Human Services released a report of its findings from an audit of FY16 and FY17 hospital inpatient claims to determine whether hospitals complied with Medicare billing requirements when assigning severe malnutrition diagnosis codes. The OIG found that 173 of 200 claims reviewed did not correctly bill Medicare for severe malnutrition diagnosis codes (E41 and E43), resulting in estimated overpayments of $1 billion. The OIG recommended the Centers for Medicare & Medicaid Services (CMS) attempt to recover the overpayments.

In November 2021, the Office of the Inspector General (OIG) announced inclusion in its Work Plan a new project to assess the accuracy of Medicaid payments for the treatment of severe malnutrition.

The Academy serves on A.S.P.E.N.'s Malnutrition Coding and Reimbursement Task Force, which has been working to help the U.S. Department of Health and Human Services, the OIG, and the Centers for Medicare & Medicaid Services understand the best practices for diagnosing, documenting, and coding malnutrition. As part of their strategy the Task Force has met with CMS and CMS auditors to share concerns about the lack of transparency around criteria used in reviewing such claims and offer education/resources.

The Centers for Medicare & Medicaid Services announced in its Inpatient Prospective Payment System Final Rule for Fiscal Year 2020 that it would not be reclassifying the malnutrition diagnosis codes. The Academy joined the American Society for Parenteral and Enteral Nutrition, the American Society for Nutrition and the Association of Clinical Documentation Improvement Specialists in a request to the CMS to postpone the reclassification of codes earlier this year.

Malnutrition Clinical Characteristics Validation and Staffing Optimization Study

The Academy's Nutrition Services Coverage Committee organized the original workgroups to establish characteristics and sentinel markers for malnutrition diagnosis codes that RDNs can use in documenting adult and pediatric malnutrition in hospital acute care and other settings. The Malnutrition Clinical Characteristics Validation and Staffing Optimization Study is currently underway by the Academy’s Nutrition Research Network to validate the Malnutrition Clinical Characteristics. The study will also examine the amount and level of RDN care necessary to improve patient outcomes - overall and in the context of malnutrition.

Adults

In 2010, the American and European Societies of Parenteral and Enteral Nutrition recommended use of an etiology-based nomenclature to describe adult malnutrition since ICD terminology fails to incorporate the impact of the inflammatory response on nutrition diagnosis, assessment and treatment. The Academy of Nutrition and Dietetics concurred and recommends that when adult malnutrition is diagnosed, the following descriptive terminology be used to more fully elucidate the context in which malnutrition occurs:

  • Malnutrition in the context of acute illness/injury.
  • Malnutrition in the context of chronic disease(s)/condition(s).
  • Malnutrition in the context of environmental or social circumstances.

Joint expert panels convened by the Academy and A.S.P.E.N. delineated an initial set of clinical characteristics to facilitate the standardized recognition and documentation of adult malnutrition by RDNs, Primary Care Providers (PCPs) and other members of the health care team. Some of these characteristics may change over time, as evidence to support their appropriateness is collected and evaluated on a broader scale. However, at this time, the Academy and A.S.P.E.N. feel that these characteristics best support a diagnosis of adult malnutrition, characterize its severity, and most rapidly and accurately reflect improvement or decline as nutrition status changes.

The nutrition parameters assessed and documented by RDNs are critical pieces of information used by PCPs, facility-based coders and others to validate a diagnosis of adult malnutrition (MS-DRG). A standardized approach to malnutrition recognition and documentation will help to ensure that adequate human and financial resources are available to optimize care for this highly vulnerable population.

Practice Tools and Resources

Serum Proteins

The Academy Evidence Based Practice Nutrition Screening Workgroup reviewed several questions on albumin and prealbumin. Academy members can review this information on the EAL website - Nutrition Screening Evidence Analysis Project. Members will need to log into the EAL in order to access the Nutrition Screening information, including their review and analysis of serum proteins.

Pediatrics

A joint expert panel convened by the Academy, A.S.P.E.N. and the American Academy of Pediatrics delineated an initial set of clinical characteristics to facilitate the standardized recognition and documentation of malnutrition among children (ages 1 month to 18 years) in routine clinical practice. The universal use of a single set of diagnostic parameters will expedite the recognition of pediatric undernutrition, lead to the development of more accurate estimates of its prevalence and incidence, direct interventions and promote improved outcomes. The nutrition parameters assessed and documented by RDNs are critical pieces of information used by physicians, facility-based coders and others to validate a diagnosis of pediatric malnutrition. A standardized approach to malnutrition recognition and documentation will help to ensure that adequate human and financial resources are available to optimize care for this vulnerable population and help to further ensure the provision of high-quality, cost-effective nutrition care.

Practice Tools and Resources


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