Case Study: From Misreporting to Compliance: How Hospitals Can Implement a Standardized Process for Severe Malnutrition ICD 10 Diagnosis Codes

Case Study: From Misreporting to Compliance: How Hospitals Can Implement a Standardized Process for Severe Malnutrition ICD 10 Diagnosis Codes

In 2021, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) initiated an audit of Inpatient hospital Medicare claims reporting severe protein-calorie malnutrition (SPCM) diagnosis codes (Medicaid Inpatient Hospital Claims With Severe Malnutrition, 2021). The full-scale audit was prompted after a sample OIG audit in 2020 found that only 27 out of 200 claims correctly billed Medicare for severe malnutrition diagnoses. Of the 173 incorrectly billed claims, 164 claims reported severe malnutrition ICD 10 codes when they should have used a different malnutrition code or none at all. The overcoding discovery resulted in $914,128 in net overpayments. Following these calculations, OIG estimated that hospitals overbilled Medicare for severe malnutrition by $1 billion in 2016 and 2017 (Grimm, 2020).

Given that severe malnutrition MCCs increase the dollar amount in Medicare reimbursements, overcoding is a potential risk for all healthcare organizations. For this very reason, health systems need to audit their Inpatient hospital claims to proactively identify and resolve any misreported severe malnutrition cases.

We provide the full case study to clients, partners, and upon request. To request access to the full case study, please send your name, company, title, and contact information to info@yes-himconsulting.com. Download an Executive Summary of the case study findings.

Challenges That Inpatient Coders Face

Inpatient coders are not clinicians, but they may be expected to review the clinical elements and documentation in a patient’s chart for provider queries and/or physician advisor reviews in order to assure quality coding. Coders can only reach a conclusion with the written documentation to which they have access. Hospitals need to develop a clinical review process for Inpatient coders to escalate a patient’s record for specific diagnosis codes based on the documentation available in the record. Hospitals require a standardized form for Inpatient coders to fill out and initiate the review process. Physician Advisors (PA) need response criteria to provide feedback on their final selection to the Inpatient coder.

The key objectives of this case study were the following:

• Proactively review severe protein-calorie malnutrition cases.
• Examine the physician advisor review procedure.
• Establish a standardized review process between Inpatient coders and physician advisors, and provide better feedback to assist Inpatient coders in their daily operations.
• Identify areas of improvement and educational opportunities for the clinical documentation improvement (CDI) team, providers, and Inpatient coders.

Results of The Severe Malnutrition Case Study

After three years, the SPCM Compliance and Improvement case study yielded the following results:

We analyzed the client’s Inpatient severe protein-calorie malnutrition cases, standardized the review process, and provided information on how to accurately identify these cases to the client’s Inpatient coding department and CDI Team.

The data shows that the overall disagreement rate with the PA was far higher in the SPCM cases initiated by the facility’s CDI Team. We saw that the disagreement rate between the YES Inpatient coders and the facility’s PA (27%) to use the SPCM diagnosis was far lower than that between the facility’s CDI Team, coder, and PA (57%). In the SPCM cases initiated by the facility’s CDI Team for further review, there was a 30% increase in final conclusions that disagreed with the coder’s recommendation, signaling that the CDI Team may have utilized different criteria that constitute a SPCM diagnosis code.

Additionally, if a facility experiences a high disagreement rate between the number of documented severe protein-calorie malnutrition cases and the PA’s final selection, the biggest opportunity for education lies with the medical staff to provide more appropriate documentation.

In conclusion, the case study presented the best approach to address OIG compliance and additional improvement opportunities for hospital staff. By analyzing the case study’s findings, our team recommended regular audits of severe protein-calorie malnutrition cases monthly or quarterly.

Our consultants developed a standardized severe protein-calorie malnutrition form template for Inpatient coders to submit their documentation findings to the hospital’s PA. To further streamline the review process, we designated PA response criteria while making the final code selection and providing feedback to the coder.

Finally, the case study identified additional education opportunities on consistent severe protein-calorie malnutrition coding, as well as variations in criteria utilized by different teams.

Next Steps for Your Team

Would you like to proactively audit your Inpatient severe protein-calorie malnutrition cases? Reach out to our team of auditing experts today to discuss our solutions. Our scope of HIM services includes coding support, consulting, education, and more.

We provide the full case study to clients, partners, and upon request. To request access to the full case study, please send your name, company, title, and contact information to info@yes-himconsulting.com. Download an Executive Summary of the case study findings.

Sources

• Grimm, C. A. (2020). Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims. Office of Inspector General.
• Hospitals Billing for Severe Malnutrition on Medicare Claims. (2020). Retrieved from U.S. Department of Health and Human Services Office of Inspector General: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000258.asp
• Kris M. Mogensen, M. R.-G. (2015). Malnutrition in Older Audits. Today’s Dietitian, 56.
• Medicaid Inpatient Hospital Claims With Severe Malnutrition. (2021). Retrieved from U.S. Department of Health and Human Services Office of Inspector General: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000628.asp