News: California facilities struggle with allegations of inappropriately billing for kwashiorkor

March 3, 2011

If the data is true, the population of a couple of concentrated areas in California suffer from kwashiorkor syndrome, a type of malnutrition typically seen among children in third-world countries, according to a recent report from California Watch. Two facilities owned by Canada-based Prime Healthcare Services reported between 40 and 70 times the state average of kwashiorkor cases. Shasta Regional Medical Center in Redding, CA, reported that 16.1% of its Medicare patients 65 and older suffered from this type of malnutrition and Desert Valley Hospital in Victorville, CA, reported 9.1% of its Medicare patients were treated for the disease, California Watch reported.

As CDI professionals know, however, when a physician documents the clinical condition/diagnosis of “protein malnutrition” it translates to kwashiorkor in the coding language of ICD-9-CM, to code 260, which is a MCC, says Gloryanne Bryant, RHIA, CCS, senior director corporate coding and HIM compliance department at Catholic Healthcare West in San Francisco, in the ACDIS Blog post, Malnutrition continues to be area of clinical concern.

The following ICD-9-CM codes denote more commonly seen types of malnutrition:

263.0, malnutrition, moderate
263.1, malnutrition, mild
263.2, arrested development following protein-calorie malnutrition
263.8, other protein-calorie malnutrition
263.9, unspecified protein-calorie malnutrition

Coding Clinic, fourth quarter, 1992 attempts to clarify the need to document the severity of malnutrition in adult hospitalized patients. It says:

“Malnutrition is generally thought of as a problem associated with children. Increasingly, it is becoming a problem for the elderly of this country who are unable to properly care for themselves, and who do not have the resources to obtain daily care…In order to improve the reporting of malnutrition among the elderly, it is important for physicians to document the condition in the medical record and for coders to be aware of malnutrition as a potential diagnosis.”

The California Watch report found that only 1.3% of Medicare patients in the state were diagnosed with the types of severe malnutrition which offer the greatest amount of federal reimbursement dollars. Prime’s rate for these conditions was 10.1%, according to California Watch’s information.

Prime is not the first to come under investigation for escalated cases of malnutrition. In fact, Jamie Bennett, Assistant U.S. Attorney, District of Maryland, successfully prosecuted Johns Hopkins Bayview Medical Center for CDI-matters related to malnutrition and acute respiratory failure. The suit was resolved when the facility agreed to pay the United States $2.75 million, according to a press release from the United States Attorney for the District of Maryland, at the time. (Bennett will discuss the implications of that case for CDI programs at the 2011 ACDIS Conference in Orlando on Thursday, April 7, 9:15-10:15 a.m.)

Prime is also under investigation for another frequently mis-documented and inappropriately coded condition—septicemia. In July 2010, Rep. Peter Stark and Rep. Henry Waxman requested an investigation of Prime regarding its facilities’ high instances of septicemia. The term “septicemia” does not exist in the ICD-10 code set. When referenced the ICD-10 index points to R78.81, bacteremia, not otherwise specified.