Severe Malnutrition Contributes to Claim Denials

Growing evidence suggests that claim denials are often based on a secondary diagnosis of severe malnutrition.

Hospital inpatient denials continue at a furious pace. From a Health Information Management Coding and Clinical Documentation Integrity (CDI) perspective, there is compelling evidence of a pattern of denied claims with a principal or secondary diagnosis of sepsis, a principal or secondary diagnosis of acute respiratory failure and denied hospital inpatient claims with the secondary diagnosis of severe malnutrition. How do we address and respond to these denials?

Finding the root cause of the denial and then identifying solutions is the direction we should be taking; both will improve compliance and obtain accurate patient severity data and reimbursement. When it comes to denials for a diagnosis of malnutrition, we have seen an additional focus on severe, moderate and even mild malnutrition. These are represented by ICD-10-CM codes of E43 Unspecified Severe Protein-Calorie Malnutrition, E44.0 Moderate Protein-Calorie Malnutrition, and E44.1 Mild Protein-Calorie Malnutrition. The specific codes can impact the MS-DRG payment and can also impact payment under risk adjustment, hierarchical condition categories.

With all the documentation details and clinical criteria floating around it can be overwhelming. The first thing to do is to create a tracking log or tool for all your clinical denials and also your coding denials (if they occur). At a minimum, excel spreadsheets will work well. Within your tracking log be sure to collect the patient identifiers like medical record number, discharge date and patient name. List the diagnosis being denied and the ICD-10-CM code and the payer. Next have columns for different elements or diagnostic criteria which caused the denial by the payer (i.e., include “conflicting documentation,” “lack of clinical indicators,” lab values – normal/abnormal, etc.), then add your own review elements too. This log will provide great information and help to identify trends and patterns.

Let’s not confuse the criteria published by InterQual, Milliman, and MCG (Clinical Guidelines) as these are mainly used to determine the hospital admission status, level of care and medical necessity of care. All these clinical criterions continue to be a little fluid and are constantly evolving as the world of medicine continues to spread in our digital era resulting in improvement of patient care and outcomes.

In addition, we have the European Society for Clinical Nutrition and Metabolism, the Latin American Nutritional Federation, and the Parenteral and Enteral Nutrition Society of Asia who published the “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community,” in the Journal of Parenteral and Enteral Nutrition. Also, the American Society for Parenteral and Enteral Nutrition criteria for malnutrition have been applied in an acute care setting. There is a large amount of information published on the diagnosis of malnutrition. (You can visit their websites and obtain specifics on the clinical criteria aspects.)

There are also multiple resources and information published regarding the diagnostic coding of malnutrition, which include ICD-10-CM Official Guidelines for Coding and Reporting, and the American Hospital Association Coding Clinic for ICD-10-CM/PCS. Every coding professional must review and abide by these two resources.

Of course, the clinical documentation certainly is the key and at the center of most denials, but if there is conflicting, contrasting, incomplete, or missing documentation then we must query the provider for clarification, adhering to the AHIMA/ACDIS Practice Brief of 2019. That being said, the topic of provider “co-signature” on a nutritional note has been identified with some payer denials. I have always wondered about this practice of having a co-signature on a nutritional note as the only source for the code assignment for that specific diagnosis.

The individual responsible for determining the diagnosis used for code assignment is the attending physician/provider who is licensed by the state medical board and the Centers for Medicare & Medicaid Services (CMS) approved. However, when looking at the scope of practice for nutritionists, questions arise. Can the nutritionist make a diagnosis determining? Does the co-signature mean the provider agrees with the diagnosis that is on the nutrition screening, assessment, or notes?

Does this circumvent the actual diagnosing of the condition by the provider who is licensed to do so? Is this co-signature sufficient to replace the actual provider documenting his/her own assessment for a malnutrition diagnosis? Well, many payers do not think the malnutrition diagnosis with a co-signature on a dietary note is sufficient to be the only documentation support for the Malnutrition ICD-10-CM code assignment, and I agree.

I have discussed this at the AHIMA level as well and they also concur that this practice does not provide a documented diagnosis from the physician. If it is or was sufficient, then we would have respiratory therapists documenting a diagnosis of respiratory failure and asking the provider to co-sign it, so it will be coded. If it is or was sufficient then we would have Wound Care nursing diagnoses co-signed by the provider so it would be coded and so on.

Do not get into the habit of short-cutting and/or circumventing complete and accurate clinical documentation of the provider for coding of a diagnosis.

Remember this diagnostic information needs to come from the CMS-approved provider who is legally accountable for making that diagnosis in the first place. When there is a provider co-signature on a dietary diagnosis of malnutrition, it is best practice to initiate a query for confirmation and obtain provider documentation. Have a discussion with the patient care team and CDI staff. Next, I would recommend having a written policy in place that provides guidance for both Coding and CDI to query whenever there is only a co-signature on nutritional notes, respiratory therapy, wound care, etc. This could be a helpful step in decreasing denials for Malnutrition and other denials as well.

So, do not let the denials get you down. Be proactive rather than reactive and look for the root cause and the best ethical and compliant solutions!

And at the end of the day, “Do what is right!”

Reference:

https://www.mcg.com/care-guidelines/care-guidelines/; https://www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center/