Note from the ACDIS Director: OIG on the airwaves, severe malnutrition denials takes center stage

by Brian Murphy

By now most CDI professionals have likely seen the July Office of Inspector General (OIG) audit report, which can be found here. If you haven’t, that link is your required reading for the week.

To summarize: The OIG conducted an audit of $3.4 billion in Medicare payments for 224,175 claims with a discharge date in fiscal year (FY) 2016 or 2017 that contained a severe malnutrition code as the only MCC on the chart. This means that removing the diagnosis code would change the DRG. The audit sample consisted of a random sample of 200 claims with payments totaling $2.9 million. A subcontractor for the OIG performed both medical and coding reviews to determine whether the services were medically necessary and properly coded.

According to the OIG, audit findings demonstrated that hospitals correctly billed Medicare for severe malnutrition for only 27, and that hospitals incorrectly billed Medicare for the remaining 173. For nine of these claims, the medical record documentation supported a secondary diagnosis code other than severe malnutrition, but the error did not change the DRG or payment. The remaining 164 claims, according to the audit, demonstrated that hospitals used severe malnutrition codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all, which resulted in net overpayments of $914,128.

On the basis of these sample audit results, the OIG estimates that hospitals received overpayments of $1 billion for FYs 2016 and 2017.

The report left many unanswered questions, but this week on the ACDIS Podcast we were pleased to host Joseph Girardi, CGFM, CFE, an assistant regional inspector general for audit services with the U.S. Department of Health and Human Services (DHHS), OIG, Office of Audit Services. Girardi managed this particular audit, and added additional information and details not covered in the audit report above. Among the new information we learned:

• The OIG used a third-party auditor that included a certified coding specialist and a licensed physician to perform the chart reviews
• The auditor reportedly used American Society for Parenteral and Enteral Nutrition (May 2012) criteria when determining whether the patient had severe malnutrition
• The 224,175 claims from the larger audit sample in the report referenced above have been passed on to CMS for potential Medicare Administrative Contractor review

You can listen to the full episode, as well as register for future episodes of the ACDIS Podcast on the ACDIS website, or listen on-the-go via Apple Podcasts, Google Play, or Spotify.

CDI professionals will continue dealing with considerable uncertainty regarding compliant capture of malnutrition, even in the wake of the podcast and Girardi’s additional insights into the report. One key takeaway is to make your claims as denial-proof as possible up front. Include not just the diagnosis but all available clinical indicators, as well as treatments. Make sure these are well documented throughout the record.

For example, consider this tip from ACDIS member Michelle Barrett. A three, five, or seven-day hospital stay is not going to cure a patient with severe malnutrition. So, clinicians should document the hospital interventions for the diagnosis in the discharge instructions when the patient is discharged. If a patient is given nutrition shake twice a day in the hospital, or receives another recommendation from the dietician, have that documented as part of the discharge instructions. If a patient can’t eat three meals per day, and a dietician recommends more frequent smaller meals at home, document it. This practice helps to firm up the sincerity of the diagnosis and associated treatment, Barrett says, and prevents denials.

Another tip: Reach out to your Medicare Administrative Contractor and ask what malnutrition criteria they use to review claims. Try to get on the same page with the criteria they, and your organization, use to diagnose severe and other forms of malnutrition.

Editor’s note: Murphy is the director for ACDIS. Contact him at bmurphy@adcis.org. The November/December edition of the CDI Journal will focus on denials management, so if you have a malnutrition-related story to tell, please reach out to ACDIS Editor Linnea Archibald and Associate Editor Carolyn Riel.