When I was a physician advisor, our system had a malnutrition crisis. It wasn’t that we had an explosion of unexpected cases; we were not getting the diagnosis captured when it was clinically present, relevant, and significant. When we created an electronic solution of having the provider attest to the dietitian consult, we decreased our 20-percent malnutrition query rate significantly.

I know I am a broken record on this topic, but we must train providers to practice excellent medicine, making correct diagnoses and then documenting them in a codable format, including indications of why they are clinically significant and how they are being evaluated, treated, managed, or monitored.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report last week titled “Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims.” There have been numerous previous audits by the OIG on other hospitals and systems regarding malnutrition, and this won’t be the last, either. Their findings consistently suggest that institutions are capturing severe protein-calorie malnutrition inappropriately – and, therefore, considerable funds have been overpaid.

The essence of this case is that they reviewed a random sample of 200 out of 224,175 claims from fiscal years 2016 and 2017 in which E41, Nutritional marasmus, or E43, Unspecified severe protein-calorie malnutrition, were the sole major complication or comorbidity (MCC). They determined that 27 out of the 200 claims (13.5 percent) were correctly billed. For 164 claims (82 percent), they believed that malnutrition was either not a legitimate diagnosis or was not of the severity asserted. The amount of estimated overpayments was $914,128. When they extrapolated the overpayments over the entire cohort, they arrived at $1.024 billion at risk.

The OIG report references the ICD-10-CM Official Guidelines for Coding and Reporting, on page 3, detailing how the definition for “other diagnoses” indicates that an additional condition affects patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, the extension of length of stay, or increases in nursing care or monitoring needs. It also back-references UHDDS item No. 11-b, adding “all conditions that coexist at the time of admission.”

Severe PCM almost always coexists at the time of admission. I think the major issue is getting providers to document how it is affecting the patient and their management during the encounter.

Historically, auditors used outdated malnutrition criteria from the World Health Organization (WHO), circa 1999, but now they are likely to use American Society for Parenteral and Enteral Nutrition (ASPEN) or Global Leadership Initiative on Malnutrition (GLIM) criteria. The clinician has some discretion to apply a severity designation, but there must be some clinical basis.

The two examples in the OIG report are consistent with their premise. Those cases were inappropriately coded with E43 when the documentation supported other levels of severity. If you were wrong, give the money back – consider it a loan. However, I suspect there were other cases for which severe PCM was documented, but the auditor disputed the clinical validity of the diagnoses.

There are nefarious administrations that exhort providers to document conditions that are not present to increase reimbursement, but these are quite the exception to the rule. I think the more common scenario is that the patient has the condition, but the provider doesn’t bolster their diagnosis with enough detail to sufficiently support it to satisfy the auditor’s requirements. I have had providers tell me that it isn’t in their purview to diagnose malnutrition; it is the dietitian’s expertise.

Malnutrition is clinically significant. It leads to difficulty healing from trauma or surgery and recovery from acute or chronic illnesses. Their skin needs extra attention and care to protect from breakdown. Providers shouldn’t have to document this on every malnourished patient; it’s well-known.

What they need to do is acknowledge the dietitian’s consult and input, implement their recommendations, and document the diagnosis and the plan. If they disagree with the dietitian’s severity assessment, they need to detail why.

COVID-19 is going to have to share the stage with malnutrition CDI right now, or hospitals are going to be hurting. Work on this now or takebacks will be coming.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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