AHLA - Compliance Corner - OIG Malnutrition Audits Confuse Compliance - Time to Act (2023)

• 01. October 2020

• Paul Belton, RHIA, MHA, MBA, JD, LLM , Stanford HealthCare and Sharp HealthCare
• James S. Kennedy, MD, CCS , CDIMD

CWhen will we seriously start documenting malnutrition and coding the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM)?

On July 13, 2020, for the fourth time in the past five years, the Office of the Inspector General (OIG) of the US Department of Health and Human Services (HHS) released the results of its ICD-10-CM review for severe malnutrition.¹This latter report must be promptly addressed by compliance professionals and the Legal, Clinical Documentation Integrity (CDI) and Coding departments to mitigate significant compliance and financial risk to all organizations.

According to the OIG173 von 200(86.5%) inpatient consultations that reported ICD-10 CM codes E41, nutritional marasmus, or E43, unspecified severe protein-calorie malnutrition identified as the only major complication or comorbidity (MCC) associated with the Diagnoses of Medicare Severity (MS -DRG) were reported in error. It represented a vision31% payment failure rate, much higher than the 5% benchmark used by the OIG in discovery audits, which is a projected $1 billion impact on the traditional Medicare program over two years.

As a caveat, CMS Administrator Seema Verma not only agreed with the OIG's findings, but also specifically stated that "CMS will direct its Medicare subcontractors to review a sample of submissions in the sample frame that were not part of the sample but are included." are the reopening period to determine if they have been billed correctly. Based on the results of the sample review, CMS determines the appropriate course of action. CMS will collect any identified overpayments related to revisions, as appropriate, in accordance with agency policies and procedures.”²

Verma went on to explain that CMS will "review how hospitals use the E41 dietary waste diagnosis code and the E43 unspecified severe protein-calorie malnutrition diagnosis code, and will work with hospitals to ensure they have correct Medicare coverage when they... Use diagnostic codes for severe malnutrition”.³

Given CMS' acceptance of the OIG recommendations, all affected MS-DRG entities, including physicians participating in CMS bundled reimbursement programs, should prepare for a likely escalation of payer reviews addressing severe malnutrition identified as single MS-DRG-MCC, and face significant financial losses unless malnutrition definitions, documentation, and coding risks are reduced. Beyond the Targeted Probe and Educate CMS initiatives, compliance professionals must heed this wake-up call and commit their time and resources to protecting their institution's reputation and revenues.

This article presents a proposed approach employing physicians, ICD-10-CM coders, clinical documentation integrity (CDI) specialists, and compliance professionals to mitigate malnutrition denial. This approach can also be applied to other high-risk diagnoses such as sepsis, acute respiratory failure, and acute tubular necrosis. Given the reputational impact that previous OIG malnutrition audits have had on other institutions, legal counsel should also be involved in addressing these issues.⁴

A good compliance professional knows the law; one knows the law, the judge and the jury best

With any allegations of DRG-related fraud and abuse, compliance professionals must not only look at vendor documentation and facility coding basics, but also consider how outside stakeholders view the same principles to develop proactive and reactive strategies. Critical issues and stages include:

• Literature-based definitions and clinical indicators for risk terminology, which in this case includes kwashiorkor, marasmus, other severe malnutrition, non-severe malnutrition, cachexia, and sarcopenia, from provider and investigator perspectives.
• Physician decision-making practices and documentation using these terminologies, which may differ from those of their institutions or responsible officers.
• Official ICD-10-CM conventions, guidelines, and advice, particularly those pertaining to primary (first listed) and additional (secondary) diagnoses that are often unclear, imprecise, or conflicting, and, according to most providers and institutions, are usually misunderstood by Accountability Officer.
• Clinical validation practices, where providers and institutions ensure that a documented and codified diagnosis or treatment is clinically supported, and how these practices differ from those of auditors.
• CDI or coding clarification practices where an inappropriate or misleading query can invalidate the answer even if clinically correct.
• Written and approved policies and procedures for medical personnel and facilities that guide the personnel, processes, and technology involved in encoding and reporting ICD-10-CM diagnoses.
• Data analysis to identify potential omission or engagement errors that alert compliance officers and facilities to prevent or identify compliance risks.
• Adhering to OIG model compliance plans, making identified errors less likely to be interpreted as fraud.

question of clinical definitions

Crucial to any ICD-10-CM clinical validation workflow is agreement on the clinical indicators that support a documented diagnosis. In fact, the American Hospital AssociationCoding Clinic für ICD-10-CM/PCS, an official CMS-sanctioned publication that interprets the principles of ICD-10-CM/PCS, emphasizes that “an institution or payer may require a physician to use a specific clinical definition or set of criteria when he makes a diagnosis, but it is a clinical problem outside of the coding system” as a basis for clinical validation workflows.⁵

The Academy of Nutrition and Dietetics (AND), the American Society for Parenteral and Enteral Nutrition (ASPEN), and/or the American Society for Nutrition (ASN) are trusted professional organizations representing the views of researchers, clinicians, and nutritionists in the United States. Professionals whose positions can be used in making definitions. In their response to this OIG review and their request for transparency, AND, ASPEN, and ASN stated that the two consensus-based methods that define malnutrition in the United States are:

• The 2012 ASPEN/AND criteria⁶
• The global leadership 2018Criteria of the Initiative on Malnutrition (GLIM).⁷

On September 9th, 2020 Mr. Joseph Girardi, CGFM, CFR, an OIG Assistant Regional Inspector General, explained on a podcast that physicians working for their contract inspectors used the ASPEN/AND criteria in their clinical validation without providing further details on how they were applied .⁸

In addition, the Subjective Global Assessment (SGA), the Nestlé Nutritional Assessment or the World Health Organization criteria are among the alternative assessment tools that researchers or payers use to define malnutrition and its severity.⁹Even when facilities and clinicians use ASPEN or GLIM criteria in their nutritional assessments, compliance professionals should insist on knowing or negotiating what alternative criteria liability officers or payers can use to anticipate their denials and how to avoid them.

Other relevant ICD-10 CM codes and definitions include:

• E41, nutritional marasmus—"A chronic condition of severe malnutrition" based in 1972 on a severe degree (Stage 3) of stunting (height < 85%) or emaciation (weight < 70%).¹⁰From a US coding perspective, the Coding Clinic notes, "First, it should be noted that marasmus is, by definition, a type of protein-energy malnutrition occurring in infants or young children and caused by severe caloric deficiency," which even points to it notes When a physician documents marasmus in an adult, he must be very reluctant to attribute E41, nutritional marasmus, without further claim or justification.¹¹
• E40, Kwashiorkor- Severe malnutrition or wasting with edema and in some cases dermatoses.¹²Although attributed to third world countries, kwashiorkor has been described in the United States with cerebral palsy, pancreatic insufficiency, and anorexia nervosa.¹³The Coding Clinic states that kwashiorkor is extremely rare in the United States.¹⁴
• E42, Marasmus und Kwashiorkor— Applies if the patient has characteristics of both diseases. As noted above, facilities should be reluctant to report codes E42, Kwashiorkor, and Marasmus without explicit proof of this documented diagnosis by the provider.
• R64, Caquexie—Linear tissue mass loss that involves a weight loss of more than 5% of body weight in 12 months or less in the presence of a chronic disease or with a body mass index (BMI) of less than 20 kg/m2in the context of three of the following statements:
  • Decreased muscle strength
  • fatigue
  • Anorexia,
  • low fat-free mass index,
  • Elevated inflammatory markers such as C-reactive protein or interleukin (IL)-6, and anemia or low serum albumin.^fifteen
    
  Cachexia, a comorbid MS-DRG (CC) complication, can coexist with severe malnutrition and is often indistinguishable; Therefore, outside reviewers may attempt to substitute R64 for E43, unspecified severe protein-calorie malnutrition, to remove MCC. In addition, the Coding Clinic states that if wasting, body mass less than 70% of predicted, is documented without stating that it is due to malnutrition, R64, cachexia, should be reported instead of E41, food wasting, according to the classification by the ICD-10-CM index.¹⁶
• M62.84, Sarcopenia— Loss of strength and muscle mass without an underlying disease or condition.¹⁷With no evidence of restricted energy intake or inflammatory conditions seen in malnutrition or cachexia, responsible agents can promote this alternative diagnosis and code that is not MS-DRG MCC or CC.

Compliance professionals should work with their medical team to standardize the criteria that define malnutrition and other high-risk diagnoses (e.g., sepsis) for coding purposes and how they may differ from those related to research or clinical care. Language differences between physicians and coding departments must be consistently addressed, particularly as ICD-10-CM terminology does not always align with clinical terminology. The inclusion of these criteria in hospital and medical committee protocols and in official written policies should be mandatory. Coding and clinical CDI validation guidelines should also make explicit reference to these definitions. Ideally, these definitions should be included in payer contracts to serve as a basis for negotiating denials.

Explore the official coding conventions, guidelines, and advice for preventing malnutrition

The Coding Clinic emphasizes that the ICD-10-CM coding is based solely on the provider's documentation of the applicable diagnoses that influenced the encounter.¹⁸While it seems simple, other conflicting advice from the Coding Clinic confuses this approach. Problems include:

• The ICD-10-CM guidelines require that "to select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first search the term in the alphabetical index and then search the code in the tabular list." look up . Read and be guided by the clues that appear in both the alphabetical index and the tabular listing.”¹⁹If the documented term is not in the index, it may not be codified unless the coding clinic grants an exception or an institution has reasonable confidence that a substituted term would stand up to scrutiny. Synonyms for severe malnutrition, such as B. Severe hunger, starvation, anorexia, or starvation cannot be coded as severe malnutrition unless the physician uses the appropriate language in the ICD-10-CM index.
• The Coding Clinic specifically states, "A basic rule of coding is that if the code title suggested by the Index does not correctly identify the condition, further searches are performed."²⁰Regarding the weight loss guidance cited above, the Coding Clinic does not specify how to conduct further research to ensure that the ICD-10-CM code accurately reflects the patient's condition. Provider advice is therefore essential to bridge this dilemma.
• The ICD-10-CM guidelines state that “the importance of consistent and complete documentation in the medical record should not be underestimated” but do not define what constitutes consistent documentation.²¹Many payers reject claims when a provider documents a risk condition only once, claiming that "consistency" requires diagnoses to be documented more than once and/or in the discharge report. The American Health Information Management Association (AHIMA), one of the collaborating parties to ICD-10-CM, provides the only official definition of "consistent documentation" that includes "nonconflicting" or "nonconflicting" in its ICD Outpatient Toolkit. means. .²²The Coding Clinic provides clear examples where documented diagnoses can only be coded once and do not have to be on the discharge report.²³Therefore, rejections based on the lack of repetition of a clinically valid diagnosis must be refuted.

More recently, the Coding Clinic has provided important advice on coding for malnutrition, including:

• Malnutrition is not an integral part of cancer or other non-nutritional diagnoses, contradicting several statements made in previous OIG audits.
• Non-severe malnutrition that is present at the time of admission and progresses to severe during admission should be coded as severe and reported as being present at admission.
• ICD-10-CM coding of malnutrition based solely on a provider's consent to a nutritional assessment should only be used when governed by a facility's policy.²⁴

Consequently, if co-signing of dietary notes were the sole determinant of ICD-10-CM coding without a supporting written policy, this coding practice would likely fail retrospective scrutiny and result in a denial.

Probably the most problematic reason for denial is whether a malnutrition provider's documentation meets the ICD-10-CM guidelines' definition of an "additional diagnosis" requiring clinical evaluation, therapeutic treatment, diagnostic procedures, prolonged hospitalization, or enhanced Requires maintenance and/or or monitoring for your reporting. Reviewers negated malnutrition codes when providers chose not to treat malnutrition based on a patient's end-of-life protocol, or stated that supplementation with enhanced dietary supplements or enteral tube feeding are not considered therapeutic treatments, although these approaches are favored in the clinical literature. Some denials focused on the lack of assessments by social workers assessing the patient's lack of access to food, or the lack of discharge planning documentation addressing how to continue the patient's nutritional therapy.

Regardless of which malnutrition criteria are used, each element supporting the diagnosis of severe malnutrition must be clearly documented by a competent assessor and readily accessible to the testing facility; the diagnosis must be documented or confirmed by an authorized provider in accordance with established policies and procedures; and the records must clearly demonstrate that the patient's malnutrition impacted the patient's need for increased care or monitoring, diagnostic testing or treatment, or the patient's outcomes and/or length of stay. While the Coding Clinic does not require confirmed diagnoses to be documented more than once, as many auditors look for repeated documented diagnoses to demonstrate provider intent, ongoing documentation of malnutrition and its impact on care by the physician without copying and Inserting the repeat prevents rejections and strengthens a facility's defense that the documented diagnosis was valid and impacted patient care or outcome.

Ensuring robust clinical validation and CDI workflows

Clinical validation has been a cornerstone of compliance efforts since the 1990s. Convalescence checkers often deny ICD-10 CM codes based on provider documentation if they believe the patient's clinical circumstances do not meet their criteria. Although the Coding Clinic specifically states that the assignment of the ICD-10 CM code is based solely on provider documentation and that each provider can define their diagnoses using whatever criteria they choose to use, AHIMA Clinical Validation Practice Summaries, CMS' 2013 Recovery Audit Contractors (RAC) The Scope of Work (SOW) and OIG and Department of Justice (DOJ) own practice of clinical validation protocols require facilities to ensure that the patient's clinical indicators support the coded diagnosis or treatment.²⁵

Even when standardized definitions of clinical validation have been established, compliance professionals struggle to direct coding departments to "self-deny," exclude, or not assign ICD-10 CM/PCS codes when clinical indicators supporting a documented condition are not are obvious. While it is common practice when a facility believes that determination of inpatient status is not supported, the Coding Clinic specifically prohibits it for ICD-10 CM/PCS coding unless permitted by the documentation provider .²⁶The protocol recommended by Coding Clinic requires consultation with the provider. "If, after consultation, the treating physician claims that a patient has a particular condition despite not meeting certain clinical parameters, the unit should encourage the physician to document the clinical justification and be prepared to defend the condition if it is found in." is challenged by an audit. The institution shall assign the appropriate codes for the documented conditions."²⁷

Compliance departments should assess whether their facility can knowingly submit a code that does not meet clinical validation criteria, knowing that the OIG or DOJ is likely to reject the code or violate the clinic's recommendation for a CMS-approved coding , which allows the coding of clinically invalid codes verified by a consulted provider. The authors believe that the risk of violating the False Claims Act or the Civil Monetary Penalties Act outweighs the consequences of not following official Codification Clinic advice. Legal advice on this subject is strongly recommended.

CDI and coding queries must comply with the 2019 AHIMA and Association of Experts in Clinical Documentation Integrity (ACDIS) Summaries of Practice and must not be perceived as “leadership.”²⁸Risk practices include “yes/no” questions to obtain a diagnosis of malnutrition not already documented in the medical record; Providing only one option (e.g. severe malnutrition) in a multiple choice query (which, although allowed, is strongly discouraged); or offer medical consultations upon receipt of a registration request from a liability agent. Verbal requests affecting vendor documentation should be tracked in an accessible database. Even if a documented diagnosis requested by the main consultation is clinically valid, failure to comply with this practice summary by the consultation puts the record at risk.

Use data analytics for goal reviews

Compliance professionals should selectively establish their audit strategies to demonstrate their organizations' adherence to the OIG model compliance plans. Benchmarking based on external administrative data provides orientation.

The FY19 MedPAR for traditional Medicare benchmarks for reporting severe malnutrition is shown in Table 1 above.

The institutions should then evaluate their own internal statistics in their risk assessment and compare them with similar institutions. Installations above the 80th percentile present a compliance risk, while installations below the 20th percentile present an opportunity for documentation and coding.

Compliance professionals can use similar data to identify risks or opportunities in other diagnoses such as sepsis, respiratory infections, acute kidney failure, and other conditions outlined in the OIG work plan.

Once potential outliers have been identified, a detection audit or investigation of sufficient scope to verify whether a compliance risk exists should be commissioned, followed by a corrective action plan if appropriate. Facilities may consider self-reporting any identified "overcoding," as required by federal law.

final thoughts

The OIG's focus on coding severe malnutrition will decrease if the CMS implements its proposal to downgrade ICD-10-CM code E43, unspecified severe protein-energy malnutrition, from MCC to CC, as in the proposed rule discussed for anticipated payment for inpatients in fiscal year 2020. In light of COVID-19, CMS delayed its decision until at least fiscal year 2022. As such, severe malnutrition is likely to remain an MCC until at least October 1, 2021, at which point proactive intervention is required to ensure.

In summary, given the recent OIG malnutrition report, compliance professionals should consider the following:

1. Conduct data analysis to measure your facility's potential risk.
2. Determine if medical personnel have established written acceptable clinical criteria for mild and severe malnutrition
3. Review a sample of inpatient medical records coded E40, E41, or E43 as the sole MCC to determine whether the patient's circumstances support the coded diagnosis and whether all coding conventions have been correctly applied. Work with legal counsel to resolve identified issues.
4. Check your coding department's coding policy for compliance with the official ICD-10-CM conventions, guidelines, or advice cited here.
5. Evaluate the ICD and coding teams' approach to provider consultation and clinical validation in high-risk diagnoses.
6. If coding uses diagnoses on a vendor-signed nutritional assessment form, ensure that this practice has policy support and that those performing the assessment have been properly trained.
7. Consider a pre-billing verification process that supports each severe malnutrition or high-risk diagnosis that serves as an individual MCC before billing. Other diagnoses may include sepsis, respiratory failure, acute tubular necrosis, type 2 acute myocardial infarction, functional tetraplegia, and others.
8. As an MCC, monitor the reporting rate of severe malnutrition in your facility and take action when it exceeds a predetermined baseline.
9. Support efforts by nutritional societies (e.g. AND, ASPEN, ASN) or the American Hospital Association to promote transparency in the OIG review process for severe malnutrition.
10. Consider negotiating these clinical validation processes with payers as part of the contracting process.
11. Connect with other compliance professionals to share experiences and solutions.

Closing remarks

1. WE.Department of Health and Human Services. Office of the Inspector General.,(OIG),Hospitals overbilled Medicare by assigning incorrect diagnosis codes for severe malnutrition to hospital claims, July 13, 2020https://oig.hhs.gov/oas/reports/region3/31700010.asp.
2. Identity.in Appendix E, CMS Comments.
3. Identity.
4. VerOIG,The University of Wisconsin Board of Hospitals and Clinics incorrectly billed Medicare hospitalization claims with severe malnutrition, 1. June 2018,https://oig.hhs.gov/oas/reports/region3/31700005.asp; OIG,Vidant Medical Center misbilled Medicare sick leave requests with severe malnutrition, 31 January 2017,https://oig.hhs.gov/oas/reports/region3/31500011.asp; OIG,Northside Medical Center incorrectly billed Medicare hospitalization claims with severe malnutrition, 30 January 2016,https://oig.hhs.gov/oas/reports/region3/31500012.asp.
5. In order to. Hosp. Ass'n (AHA), Coding Clinic for ICD-10-CM/PCS, 4. Quartal 2016, Seiten 147-149.
6. White JV, Guenter P, et al.Konsenserklärung: Academy of Nutrition and Dietetics und American Society of Recommended Parenteral and Enteral Nutrition Characteristics for the Identification and Documentation of Malnutrition in Adults (Mangelernährung), J. For parenteral and enteral nutrition(JPEN), 2012:36(3), S. 275-283,https://onlinelibrary.wiley.com/doi/full/10.1177/0148607112440285.
7. Jensen GL, Cedarholm P., et al.,GLIM criteria for diagnosing malnutrition: a consensus report from the global clinical nutrition community,J. of parenteral and enteral nutrition (JPEN), 2019:43(1), S. 32-40,https://onlinelibrary.wiley.com/doi/full/10.1002/jpen.1440.also seeI am. Society for Parenteral and Enteral Nutrition, Office of the Inspector General Report on Inpatient Hospital Billing for Severe Malnutrition, August 2020,https://tinyurl.com/yxjhwazg. For the estimated prevalence and consequences of malnutrition as defined by GLIMI understandMaeda K, Ishida Y and others,Reference body mass index values ​​and prevalence of malnutrition according to the criteria of the Global Leadership Initiative on Malnutrition,Clinical Nutrition2020:39(1), pp. 180-184.
8. Association of Experts in Clinical Documentation Integrity, Auditing of Malnutrition: A Conversation with the OIG, 9. September 2020,https://acdis.org/acdis-podcast/malnutrition-audit-conversation-oig.
9. Phillips W., Doley J., Boy K.Definitions of malnutrition in clinical practice: E43 to be or not to be?,Health Information Management J, 49(1), pp. 74-79.
10. Barltrop D, Sandhu BK,Marasmus - 1985,Diploma-Med. J.,1985, 61, pages 915-923,https://pmj.bmj.com/content/61/720/915.long.
11. AHA, Coding Clinic, Q3, 2017, pages 24-25.
12. Benjamin O, Lappin SL,Kwashiorkor, StatPearls, 2020,https://pubmed.ncbi.nlm.nih.gov/29939653/.
13. Palm CVB, Frolich JS and others,Kwashiorkor: an unexpected complication of anorexia nervosa,BMJ-Fall portraits. 2016,https://pubmed.ncbi.nlm.nih.gov/27852657/; Marks RR, Burgy JR, Davis LS,Acute kwashiorkor in cerebral palsy and pancreatic insufficiency, Cutis 2019 Jan;103(1):E10-E12,https://pubmed.ncbi.nlm.nih.gov/30758347/.
14. AHA, Coding Clinic for ICD-10-CM/PCS, 3. Quartal 2017, Seiten 25-26.
15. Soc'y on Sarcopenia, Cachexie and Wasting Disorders, Definition of cachexia and sarcopenia,https://society-scwd.org/cachexia-definition/.
16. AHA, Clinical Coding for ICD-10-CM/PCS. 2017, Q3, pages 24-25.
17. VerSoc'y on sarcopenia, cachexia and wasting disorders,Aboveuse 15.
18. AHA, Coding Clinic, Quarter 4, 2016, pp. 147-149.
19. CMS and NCHS – Official ICD-10-CM Coding and Reporting Guidelines, FY2020, Section I.C2
20. AHA. Coding Clinic for ICD-10-CM/PCS, 2017, 3. Quartal, Seiten 24-25.
21. CMS und NCHS – ICD-10-CM Official Coding Guidelines for Coding and Reporting, GJ 2020, Abschnitt I.C2.
22. Ich bin. Health Information Management Ass'n - ICD-10-CM Ambulantes CDI-Toolkit,http://bok.ahima.org/doc?oid=302445#.X0xEyn6SnIU.
23. AHA, Coding Clinic Q3 2012, page 22, and Coding Clinic Q3 2007, pages 13-14.
24. AHA, Coding Clinic, Q1 2020, Seiten 3-7.
25. American Association for Health Information Management. Clinical validation: January 2019 update of the next level of the CDI,http://bok.ahima.org/doc?oid=302679#.X0xDyX6SnIU.
26. AHA, Coding Clinic, Q4 2017, page 110.
27. identity.
28. American Association for Health Information Management and Association for Experts in Clinical Documentation Integrity. Guidelines for Achievement of Compliant Counseling Practice – 2019 Update,https://acdis.org/resources/guidelines-achieving-functional-query-practice%E2%80%942019-update.

Paulo R. Belton, RHIA, MHA, MBA, JD, LLM has served as Chief Compliance & Privacy Officer at Stanford HealthCare and Sharp HealthCare for the past 23 years. His work experience includes roles as former director of HIM and programmer for HIM. He currently serves as a compliance advisor in conjunction with CDIMD. It is achievable[email protected]or (619) 665-6145.

James S. KennedyMD is President of CDIMD (based in Nashville, TN) and owner of CDIMDTracker, an ICD-10 CM/PCS data analysis tool. His practice focuses on inpatient and outpatient clinical documentation and coding practices that impact ICD-10-CM/PCS-based risk adjustment for inpatients and outpatients and impact measurement of quality and reimbursement. In addition, he provides expertise in electronic medical record redesign, incorporation of principles of clinical documentation and coding integrity, litigation and audit support for compliance professionals, and training of physicians, coders and their teams on the principles of ICD-10-CM/ PCS. It is achievable[email protected]or (855) 692-3463, ext.

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