Severe Protein Calories Malnutrition in the OIG Crosshairs

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Original story posted on: August 20, 2018

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The OIG continues to review cases of malnutrition.

The diagnosis of severe protein calorie malnutrition is under high scrutiny from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

Today, I’d like to explore the reasons this is a target, what criteria are being used in these audits, and what documentation is required to ensure that physicians and hospitals receive compensation and credit for conditions they treat.

So, why is this a targeted diagnosis?

In addition to the financial impact, it has far-reaching implications for many CMS quality metrics. For example, severe protein calorie malnutrition is a diagnosis that can be used for risk adjustment for several of the CMS quality programs, including mortality and readmission penalties, as well as some of the patient safety indicators. Even if there is not an up-front financial impact from the diagnosis of severe protein calorie malnutrition, it still may have financial implications for value-based purchasing on the back end. From CMS’s perspective, they want to ensure it is coded appropriately.

Now that we know why these diagnoses are being pursued by CMS, what criteria are government agencies using for the auditing of this condition?

The short answer is that the hospitals that have been subjected to these audits feel that clear criteria have not been well-delineated. In a presentation from Novitas solutions in June 2018, they referenced criteria from both the Merck manual and the American Society for Parenteral and Enteral Nutrition (ASPEN).

The Merck manual does not cite medical literature references that support the criteria in the publication. Many clinicians do not feel that these criteria are supported by current standards in the medical literature. Novitas did state, however, that ASPEN criteria should be considered, but also supported by clinical documentation.  

Recently, the University of Wisconsin was fined $2.4 million for overpayments on malnutrition diagnoses. The University suggested it believes that the use of a diagnosis code for severe malnutrition in each of the claims met the definition of a secondary diagnosis, and that there was adequate documentation to support the assignment of the diagnosis codes. They also stated that the guidance used for the review was vague, and that the OIG did not specify any standard for the hospital to use in diagnosing severe malnutrition. The University of Wisconsin’s concerns seem to be echoed by many hospitals that are undergoing CMS audits for this particular diagnosis.

Given some of the confusion surrounding the criteria for this diagnosis, what is the best strategy to capture it?

Efforts should be both internal and external to your hospital.

Internal efforts include engaging your nutrition leadership, clinical documentation improvement (CDI) and coding team, denials department, compliance, and a physician champion to devise the best strategy to ensure that accurate and consistent documentation is present throughout the chart.

It is important to have a clear, system-wide definition of these diagnoses that are supported by the medical literature. Most hospitals use ASPEN criteria.

The next step is to ensure that the documentation supports the criteria. It is helpful for providers to document physical descriptors of the patient, such as having fat or muscle loss, what treatments they are receiving for malnutrition, and how the diagnosis may affect their medical condition.

External efforts should focus upon gathering information that can enhance your internal processes. It is crucial to keep abreast of the latest updates from CMS, OIG audit reports, and information-sharing from other hospitals on probe-and-educate results.

I wish I could provide clear and concise criteria, but until that becomes available, I recommend engaging experts at your hospital to have the most comprehensive approach to the issue.


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Megan Cortazzo, MD

Megan Cortazzo, MD is an assistant professor of physical medicine and rehabilitation at the University of Pittsburgh School of Medicine. She serves as the medical director of CDI and HIM for the UPMC System. She collaborates with multiple departments within the system to work on initiatives to improve documentation integrity.

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