Malnutrition and Inpatient Admission – Two Updates

Today’s first topic is an update to something I reported about on Monitor Mondays back in 2017: a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit of malnutrition coding of what was then called Vidant Health, now called ECU Health. That audit found that Vidant was overpaid $1.4 million for patients when malnutrition was a secondary diagnosis coded on the claim.

That audit, as I discussed in 2017, had many quite questionable decisions made by the OIG’s contracted auditor. For example, the auditors did not use any criteria to define malnutrition, despite the availability of the widely accepted American Society for Parenteral and Enteral Nutrition (ASPEN) criteria, and they claimed that some malnourished patients were not treated enough to have the diagnosis coded – despite no such requirement appearing in the coding rules. But Vidant did not accept the finding. First, they wrote a masterful response to the OIG back in 2017, which you can read at the link above, and they proceeded to appeal almost every one of the denied cases.

And as Nina Youngstrom reported last week in her newsletter, the Report on Medicare Compliance, ECU Health finally made it to the administrative law judge (ALJ) level – and they won every single case. Amazingly, the judge read each case and ruled on each individually. Nina also reports that the judge was not kind to the OIG auditor, stating in the decision “I further agree with the appellant that the contractors applied unpromulgated rules requiring that weight loss and/or muscle wasting over a defined period of time must always be present in order to diagnose severe muscle wasting and by prohibiting severe malnutrition from being coded where it is a manifestation of another condition.”

Any of you involved in clinical documentation integrity (CDI) should go to that link and read the article, or ask your compliance officer to read this issue of Nina’s newsletter. And I want to thank Dr. Vaughn Matacale at ECU Health for sharing their success story with everyone.

Next is something I am hesitant to report here.

Last week, Livanta, the Quality Improvement Organization (QIO) that has the Centers for Medicare & Medicaid Services (CMS) contract to review short inpatient stays, released a newsletter titled Short Stay Review – The Inpatient Admission Decision.

It turns everything we have learned over the last 10 years about the Two-Midnight Rule on its head. Let me start by saying that I have already written to Livanta, asking that they review the contents carefully and ensure that the article truly represents their formal interpretation of CMS policy – and I have asked CMS to review it to ensure that CMS approved the contents. So, my recommendation for now is to procced with caution with any process changes.

Now, with all that, what did Livanta say?

Well, first, they called observation a status. You all know how much I hate that. They also referred to MCG guidelines as Milliman. That bugs me, but less so.

But the big things were their examples of one-midnight inpatient admissions that were compliant. They stated that acute surgical conditions such as cholecystitis and appendicitis can always be inpatient, even if the expected discharge will be the next day. They provide no justification for this recommendation, without any comment about the case-by-case exception. The healthy Medicare beneficiary who arrives at 7 a.m. in the ED with abdominal pain, goes to the OR at 10 a.m. and stays overnight can be an inpatient? That seems to me to be a stretch.

Then they cite two medical cases: a patient with angioedema who improved with ED treatment and was never in distress, and a GI bleeding patient had a hemoglobin of 10.8 with stable vital signs, known diverticula that bled six weeks prior, and no active bleeding in the ED. In both cases, Livanta said that the concern for an adverse event warranted inpatient admission under the case-by-case exception.

As a reminder, the case-by-case exception does allow inpatient admission, despite the lack of a two-midnight expectation for patients who are deemed to warrant it, based on “the risk of an adverse event.” I am more than happy to accept this, if that is official CMS policy, but aren’t we concerned about an adverse event for every patient we hospitalize? These two patients certainly warranted hospital care, and seemed to have an expectation of less than two midnights, but their risk of an adverse event does not seem to be exceptionally high, compared to many other patients. Additionally, Livanta made absolutely no reference to the presence or absence of physician documentation supporting high risk. If the doctor had written “although this patient’s angioedema has nearly resolved, they remain at high risk for a sudden recurrence, and inpatient admission is warranted,” I would have had much more support for their conclusion.

For now, if the link to the document is live, you can certainly use it in your audit responses. But proceed carefully if you are changing policy.

Programming note: Listen to Dr. Ronald Hirsch as he makes his Monday Rounds on Monitor Mondays, with Chuck Buck and sponsored by R1-RCM.