Updated on: October 27, 2017

Novitas Guidelines for Malnutrition Reported to be Outdated, not Useful for Physicians

Original story posted on: October 26, 2017

Release of outdate guidelines raises fears that other MACs might adopt them to audit providers.

The use of outdated definitions of malnutrition by a Medicare Administrative Contractor (MAC) is raising concerns that other MACs may adopt the same flawed practice.

The universally accepted definitions, known as the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines, represent the standard of care for diagnosing, documenting, and coding malnutrition in hospitalized patients. But there are reports that Gateway Health, a Medicare Advantage organization, will adopt the outdated guidelines by Nov. 1.

Novitas Solutions, the MAC for jurisdictions H and L, posted a notice last week that included its initial audit issues. The notice indicated that claims with a diagnosis of severe malnutrition, ICD-10 codes E41 and E43, would be audited – and that the first round of audits, called “targeted probe and educated” (TPE) audits, would begin Oct. 23.

This notice received little attention until yesterday, when Jennifer DeLutis, MD, the physician advisor at Lancaster General Health in Pennsylvania, clicked on the hyperlink attached to the ICD-10 codes, which opened a new page titled “Levels of Malnutrition.” There she found a table indicating the definitions of malnutrition that Novitas plans to use in its audits.

It was immediately obvious to Dr. DeLutis that the Novitas definitions of malnutrition were outdated and not clinically useful. The table features percentage of normal weight, body mass index, serum albumin and transferrin, total lymphocyte count, and delayed hypersensitivity index as measurements, with the accumulated values placing each patient into one of four categories: normal, mild, moderate, or severe undernutrition. The table gives no indication about how many elements in each column are needed to diagnose a patient with that level of undernutrition.

For those unfamiliar with delayed hypersensitivity index, this is a test wherein a small amount of a fungus is injected under the skin and the amount of skin swelling is measured, similar to a tuberculosis test. This measures the body’s ability to respond to foreign substances and has been viewed as a surrogate marker for a patient’s immune system responsiveness.

In my clinical practice, which included the care of many patients with HIV and AIDS, I had not ordered a delayed hypersensitivity test in the last 20 years

Again, the current standard of care for diagnosing malnutrition in hospitalized patients is to use the ASPEN criteria, as outlined in a consensus statement from the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition. There are six ASPEN criteria: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation (which may sometimes mask weight loss), and diminished functional status, as measured by handgrip strength. (For more information on diagnosing and coding malnutrition, see ICD10monitor articles here and here.)

With further searching, I discovered that the table being used by Novitas was taken from the Merck Manual review of protein-energy undernutrition. For those unfamiliar with the Merck Manual, it is a “medical information resource used by medical professionals and patients” and produced by the pharmaceutical giant Merck & Co. It is not a medical textbook, and although it is written by medical experts, it is not subject to peer review, nor do the articles contain references.

Even more damning, this undernutrition review refers to chronic undernutrition and does not in any way apply to hospitalized patients with acute illnesses. For example, in the section on treatment, the author notes that adult malnutrition in patients with functional limitations should be treated with home meal delivery and feeding assistance.

What happened here? It’s unclear. With all the attention given to the diagnosis and coding of malnutrition, I find it hard to believe that someone from Novitas would go find the online version of the Merck manual, do a search on “malnutrition classification,” and immediately declare it the official tool for audits of Medicare patients without determining if it is applicable to the patient population being audited. 

According to Dr. DeLutis, several complaints have already been filed with Novitas. Erica Remer, MD, a member of the ICD10monitor editorial board, an independent healthcare consultant, and a clinical documentation expert, has notified Novitas that its use of this table does not represent the standard of care for diagnosing, documenting, and coding malnutrition in the hospitalized patient.

I am sure we will be hearing more about this in the near future; keep an eye on RACmonitor and ICD10monitor for updates. And let’s hope the other MACs do not follow Novitas’s lead. 

For more information regarding Malnutrition, click here to view ICD10monitor's webcast "Learn the Impact of Malnutrition on ROM, SOI and CMI" available on CD and On-Demand. 

Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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