Good Samaritan, an affiliate of MedStar Health System in Baltimore, agreed to pay $793,548 to resolve allegations that the hospital up-coded inpatient claims by adding malnutrition as a secondary diagnosis when it was not warranted, "used leading questions so that physicians would answer that the patient was malnourished," and used clinical forms that "injected false diagnoses of malnutrition into the record that coders used to justify the code," according to the press release. A statement from the Maryland Attorney General's Office indicated that the incorrect diagnosis was kwashiorkor (Code 260), a rare form of malnutrition in the U.S. that typically is seen only in sub-Saharan nations.
It is noteworthy that the allegations were connected to activity occurring from January 2005 to December 2008, including the pre-MS-DRG era. Under Maryland law, hospitals submit their rates to the Maryland Health Services Review Commission for a severity-adjusted reimbursement rate for all payers, including those governed by the civil FCA (Medicare, Medicaid, and federal government employees).
Code 260 is a MCC in the MS-DRG system, and the same scrutiny for compliance is applicable today.
Malnutrition is indeed a clinical problem for many patients in the U.S., resulting in adverse patient outcomes, increased lengths of stays and economic burdens for the healthcare system. According to "Nutrition and Diagnosis-Related Care" (published in 2011), 35 to 55 percent of patients are malnourished at admission, and 25 to 30 percent more may become malnourished while an inpatient.
In the United States, the Joint Commission mandates nutrition screening within 24 hours of admission to an acute-care medical center.
The Conundrum of Accurate Malnutrition Coding in ICD-9
The existing codes for malnutrition are outdated and do not accurately denote current standards of care or clinical diagnoses related to malnutrition. This results in inconsistent coding, compliance risks and inaccurate clinical data, which is necessary for population health management.
The ICD-9-CM Coordination and Maintenance Committee met with the American Dietetic Association (ADA) and the American Society for Parenteral and Enteral Nutrition (ASPEN) in September 2010. Requests were made for new codes that would better describe the many forms of malnutrition affecting both the adult and pediatric populations. The requests fell on deaf ears, though - no updates or changes were made. The freeze on ICD-9-CM codes most likely will continue until ICD-10-CM finally is launched.
Because the current codes do not capture clinically accurate diagnoses, and because Code 260 clearly is a target for the RAC, OIG, and other denial agencies, ensure that your clinical documentation improvement (CDI) program establishes safeguards to avoid allegations of fraud.
Consider the following recommendations:
- Use a clinically non-leading, robust physician clarification process;
- Encourage providers to document clinical support for malnutrition diagnoses;
- Provide education to all providers;
- Collaborate with dieticians in establishing standards and agreement for malnutrition assessment tools, which should include talks about risks and clinical presentation;
- Include the clinical documentation specialists (CDS) in review of clinical forms; and
- Establish an internal review process for monitoring the use of Code 260.
Quality of care, patient outcomes tied to LOS, readmissions, complications and the cost of care are always important components of patients' nutritional status. It is imperative that clinical documentation reflects these metrics as accurately as possible using the current code set, in spite of its limitations. This must be done compliantly.
About the Author
Melinda Tully, MSN, CCDS, is Senior Vice President of Clinical Services and Education for J.A. Thomas & Associates. Melinda has 25+ years in Acute Care as a Clinical Specialist and Nurse Practitioner. Her area of specialty is clinical documentation education focused on continuous quality improvement.
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