ED. NOTE: This is the second and final installment in this important two-part series on coding malnutrition. Part I may be viewed on the RACmonitor home page.
We are continuing to discuss the issues and concerns surrounding the coding of protein malnutrition. Part I of this two-part article gave insight into the ICD-9-CM coding classification of malnutrition, which covers the degree and specific type of malnutrition.
Another area to be cautious with are electronic documentation tools or aides physicians may utilize to help with diagnosis selection. There are several aspects to having an electronic checklist that need consideration:
1. The programming of these diagnostic lists should include the input and review of a coding professional who understands the classification system.
2. Review the programming of the diagnosis lists and confirm that they are not missing all choices for a particular diagnosis or condition, i.e. degree of malnutrition. Yes, selecting a specific condition may require an additional click of the mouse by a provider, but it is worth it to obtain accuracy and specificity.
3. The very first listed diagnosis or condition on a list of diagnoses often is the one most often selected by providers or users simply because it is easiest, so training regarding specificity is vital.
4. The mapping or crosswalk of a single diagnostic term on the selection list may not link to the correct or specific ICD-9-CM code intended, so verify this.
In addition to the above guidance, some other proactive steps to take in order to validate accuracy and identify any potential RAC (Recovery Audit Contractor) risk include:
Action No. 1:
It is recommended that you run a data report starting with information dating back to October 2007, reflecting inpatient cases (in particular Medicare) with code 260 assigned as a secondary diagnosis. If you find cases with 260 assigned, these should be reviewed for accuracy - not only for documentation to support the code, but also the clinical components of the specific type of malnutrition.
Action No. 2:
Using the review of records with code 260, determine whether further clarification is needed regarding the malnutrition terminology being used by the physician or provider. If the documentation states only "protein malnutrition," it is advised that a query be initiated since this term indexes to Kwashiorkor.
Action No. 3:
Initiate physician education explaining that documentation of the term "protein malnutrition" indexes to Kwashiorkor, which is a rare form of malnutrition typically seen in starving children. Ask for clarification regarding whether the condition is actually Kwashiorkor as opposed to another type and/or degree of malnutrition such as protein-calorie malnutrition (263.9), severe malnutrition/NOS (261), severe protein-calorie malnutrition (262) or other malnutrition/NOS (263.9) - and instruct physicians to please specify type if known. It is best not to use code 260 without confirmation of actual Kwashiorkor from the physician.
Action No. 4:
Develop a query that offers an explanation and also some choices to help physicians better understand the classification of malnutrition. Here is sample wording you can use in a query: "Dear Dr. X: You have documented ‘protein malnutrition,' which ICD-9-CM classification indexes to "Kwashiorkor," a rare syndrome occurring mostly in starving children. Please clarify whether your patient had Kwashiorkor or whether he or she had ‘protein-calorie malnutrition,' ‘malnutrition unspecified,' ‘other nutritional diagnosis' (please specify) or ‘unable to determine.' Thank you."
Action No. 5:
Share information with your coding staff and your Clinical Documentation Improvement (CDI) staff who are corresponding with the physician regarding the malnutrition conditions. The good news is that there is work being done at the national level possibly to revise the indexing for malnutrition in the ICD-9-CM classification, so stay tuned on that front when the ICD-9-CM coding update comes in October.
Coding professionals need to apply basic coding competencies when processing documentation of "protein malnutrition." Being that Kwashiorkor is a type of malnutrition not often seen in the U. S., review the clinical documentation carefully. The impact of code 260 can be a MCC for the MS-DRG, which can result in a higher payment and potential RAC exposure as seen in the above example.
Another diagnosis to take a look at is "sepsis," which falls in the code range of 038.0 to 038.9. Although we've seen and heard of wonderful national efforts to identify and treat sepsis sooner to help decrease mortality, there also are concerns about being aggressive in documentation improvement efforts, and that too can impact MS-DRG payment.
Discuss this documentation and coding issue with your RAC and compliance committees. Instruct staff to be diligent, and when in doubt talk to your hospital coding supervisor or query the physician for clarification regarding protein malnutrition. Accurate documentation, coding and reimbursement will aid in maintaining compliance and diminishing potential regulatory risk.
About the Author
Gloryanne Bryant, RHIA, CCS, CCDS, is the Regional Managing Director of HIM for Kaiser's 21 acute care hospitals in Northern California. She Co-chairs the regional RAC Committee with compliance.
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References: AHA ICD-9-CM Coding Clinic; San Francisco Chronicle, California Watch 2/19/2011; Wikipedia.com; health.nytimes.com