Malnutrition Now on PEPPER

Auditors appear to be hungry to deny.

Right on schedule, the Centers for Medicare & Medicaid Services (CMS), through their contractor, has released the latest Program for Payment Patterns Electronic Report (PEPPER) data to short term acute care hospitals, containing hospital-specific date from the third quarter of fiscal year 2021. While the report continues to address the usual topics, they have added a new topic, “Severe Malnutrition” which should garner significant attention.

It should not come as a surprise to anyone that malnutrition would be a topic for inclusion. As they note in their user guide, in 2020, the Office of the Inspector General issued a report entitled, “Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims.” All those working with clinical documentation also know the controversy and confusion around malnutrition diagnosis and coding.

Malnutrition can be reported with several codes in the E40 to E46 range, depending on the clinical circumstances. Some of those codes, E40-E43, are MCCs (major comorbidities and complications) and some are CCs, meaning they could affect hospital payment. Likewise, some of the codes map to an HCC (hierarchal condition category) and can affect payment programs that use the HCC paradigm. As with all other CCs and MCCs, the presence of other codes can affect the influence of the malnutrition code on payment. In other words, if the patient has a diagnosis of severe malnutrition, E43, and also diabetic ketoacidosis and acute respiratory failure, the presence or absence of E43 as an MCC will still leave two MCCs and not affect the DRG or the payment. On the other hand, the patient who is hospitalized for cellulitis of the leg and has E43 as the only MCC, the removal of the MCC would result in a significant change to the DRG and payment.

As with all PEPPER measures, it is important to understand what they are reporting and how to interpret the data. For this measure, the PEPPER reports as the numerator the number of inpatient admissions where the malnutrition code E40-E43 is the only MCC on the claim. In other words, if that code was removed, the DRG would change and the payment to the hospital would decline. The denominator is the total number of inpatient claims with E40 to E43, whether it was the only MCC or not. In the example above, the patient with E43 and diabetic ketoacidosis would be included in the denominator but not the numerator.

Now you must look at your data and determine what it means. As with all PEPPER measures, the data do not tell you if you are doing things right or wrong. It simply compares your data to other hospitals in your state, your MAC jurisdiction, and the nation. You may be a high outlier, in the top 5% of the nation, but if every one of your claims with E40-E43 as the only MCC has robust clinical documentation to support the diagnosis, then you have nothing to fear. Likewise, if you are a low outlier, it may be that the vast majority of your severe malnutrition patients have other major comorbid conditions or complications. Clinically, that makes sense since patients with severe malnutrition are at increased risk for a myriad of complications and malnutrition is also a consequence of many chronic diseases. I am reluctant to mention it but since people will ask, the PEPPER data show that the national average rate of admissions with E40-E43 as the only MCC is 36.1% over the last year.  

So what should you do with this new measure? Contrary to what you may have heard, the auditors do not use the PEPPER to choose who to audit; they have a separate, much more robust database. But if you are a high outlier on PEPPER, then your data on those other databases probably show a similar pattern. You may want to select a sample of charts to audit to determine if the diagnosis is clinically valid. And while doing that, you should see if any other MCCs were missed. Your internal audit plan should address what to do if you find errors.

If you are a low outlier, this may be one of those instances where it is a good thing, indicating your doctors are thorough in their documentation and never miss a codable diagnosis. But you may also want to talk to your nutrition support team and ask them to watch for patients where they feel the diagnosis of malnutrition was clinically present but not properly documented. Also remember that facility size does matter. If your facility has less than 11 admissions with E40-E43 as the only MCC, your data fields will be blank so depending on your denominator you may see no data whatsoever and be perfectly “average.” In this case, the omission of data, due to CMS data restrictions, provides you no useful information at all, giving you more time to ponder the rest of the PEPPER data.

Programming Note: Listen to Dr. Ronald Hirsch report this story live during Talk Ten Tuesdays, Tuesday, Dec. 14, 10 Eastern.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Understanding the Nuances of Coding Malnutrition

March is National Nutrition Month. In honor of National Nutrition Month (March), here is a review of weight-related diagnoses. The Official Coding and Reporting Guidelines

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Preventing Sepsis Denials: From Recognition to Clinical Validation

Preventing Sepsis Denials: From Recognition to Clinical Validation

ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.

August 22, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024

Trending News

Featured Webcasts

Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

Pediatric SDoH: An Essential Guide to Accurate Coding and Reporting

This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.

August 8, 2024
Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Oncology and E/M Services: Compliance, Medical Necessity, and Reimbursement

Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.

July 30, 2024
The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!