June 22, 2023
Importance of Using Severe Malnutrition Codes Correctly
Hospitals should establish an internal process to ensure severe malnutrition diagnosis codes are billed to Medicare correctly. Nutritional marasmus (diagnosis code E41) and Unspecified severe protein-calorie malnutrition (diagnosis code E43) are two types of severe malnutrition that are classified as a major complication or comorbidity (MCC) and may result in a higher Medicare payment. It is not appropriate to report conditions that are secondary problems but do not impact the current hospital stay to increase the relative weight of the Medicare Severity Diagnosis Related Group (MS-DRG).
Hospitals Overbilled Medicare $1 Billion By Incorrectly Assigning Severe Malnutrition Diagnosis Codes
In July 2020, the U.S. Department of Health and Human Services' Office of Inspector General (HHS/OIG) issued a report titled, "Hospitals Overbilled Medicare $1 Billion By Incorrectly Assigning Severe Malnutrition Diagnosis Codes To Inpatient Hospital Claims"
. The HHS/OIG identified 173 of 200 sample claims reviewed (86.5%) were billed in error because hospitals used severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all. Per the HHS/OIG, for those claims in error, hospitals provided medical record documentation which didn't contain evidence that the malnutrition was severe or impacted patient care. For fiscal years (FYs) 2016 and 2017, these billing errors resulted in $1 billion in overpayments to hospitals.
Diagnosis-Related Group (DRG) Validation
DRG validation ensures the diagnostic and procedural information and the beneficiary's discharge status coded and reported on the hospital's claim matches both the attending physician's description and the information contained in the beneficiary's medical record. Review the DRG Validation Review guidelines and related coding review practices to ensure your medical record documentation supports any severe malnutrition diagnosis code billed on inpatient hospital claims.
Documentation Requirements
Documentation must support that the services billed were medically necessary and properly coded. The medical record should consistently confirm the presence of severe malnutrition and support the level of severity, while capturing the increased patient complexity during the inpatient hospitalization. The documentation should support the severe malnutrition diagnosis and list any contributing etiologies or what led the patient to the malnourished state. Supportive documentation can be further demonstrated through clinical assessment findings, diagnostics completed, and actions required to treat the malnutrition during both the inpatient hospitalization and in follow-up care post-discharge.
- Consistent, ongoing documentation of the severe malnutrition by the treating physician to include:
- Etiology of, and factors which contribute to, the malnourished state
- Severity of the severe malnutrition
- Significant nutritional support and therapeutic treatment provided
- Impact on the patient's care and outcomes during the inpatient hospitalization that required increased nursing care, monitoring and length of stay
- Follow-up care post-discharge
- At-risk conditions and conflicting documentation are not acceptable
- Nutrition risk screening/malnutrition screening tool detecting malnutrition
- Registered Dietitian Nutritionist (RDN) evaluation for nutrition assessment
- Assessment findings with clinical characteristics to support diagnosis
- Inadequate nutritional intake, impaired absorption, unintended weight loss, muscle wasting, body fat loss, edema, reduced grip strength, disease-related factors, etc.
- Diagnostic procedures, laboratory findings or other relevant documentation to support diagnosis
- Social worker evaluation to assess lack of access to food and how nutritional therapy will be continued, if applicable
Examples that May Support Severe Malnutrition
- Acute illness/injury present for less than three months
- Multi-trauma, surgery, prolonged intubation, or hospitalization
- Chronic illness present for three months or longer
- Metastatic disease, chronic lung disease, or HIV disease
- Social and environmental circumstances limiting access or ability to self-care
Before Billing Severe Malnutrition as an MCC
| ✓ | Was a severe malnutrition diagnosis code billed correctly? |
|---|---|
| Does the documentation support that the services were medically necessary and properly coded? | |
| Is it appropriate to report a severe malnutrition diagnosis code on this claim? | |
| Is it more appropriate to report another form of malnutrition or no malnutrition diagnosis code at all? | |
| Once you ensure the diagnosis code corresponds with the information in the medical record documentation, you are ready to submit your claim! |
Proactive Interventions Your Facility Can Implement
- Perform data analytics for claims billed with severe malnutrition as an MCC to determine any intervention required if improper billing or payment is detected.
- Perform self-audits of inpatient records with E40, E41, or E43 coded as the only MCC to determine if the patient circumstances and medical record support that the diagnosis was coded and applied properly.
- Establish written clinical criteria, policies and procedures to substantiate non-severe and severe malnutrition diagnoses for clinical and coding staff to adhere to guidelines.
- Monitor claims billed with severe malnutrition as an MCC and implement a review process to ensure the claim is properly billed and coded prior to submission.
- Network with other facilities to share experiences and identify opportunities for process improvements.
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