Guest post: Severe protein calorie malnutrition denial defense

by Brandi Hutcheson, RN, MSN, CCM, CCDS

Severe protein calorie malnutrition (PCM) or code E43 continues to be a diagnosis under fire. The reason this is a hot button diagnosis is because of the impact it creates in the medical record. CMS risk adjusts the diagnosis for its quality programs. Severe PCM affects mortality, readmissions, and patient safety indicators (PSI). It additionally has financial implications under MS-DRGs and value-based purchasing. All these reasons mean CMS wants to ensure severe PCM is coded correctly.

Recently, the University of Wisconsin was charged $2.4 million for over reimbursement on the diagnoses of malnutrition. They were confident, however, that severe PCM was supported as a secondary diagnosis on each claim. Likewise, they reported that the Office of Inspector General (OIG) review guidance was ambiguous and didn’t elaborate on standards for the hospital to use to back-up the diagnosis of severe PCM. Accordingly, hospitals should take a multidisciplinary team approach in deciding how severe malnutrition should be diagnosed including the consideration of medical literature on the subject. In saying that, most facilities use the American Society for Parenteral and Enteral Nutrition (ASPEN) benchmarks for malnutrition diagnoses.

If a facility does employ ASPEN criteria for malnutrition guidelines, it is prudent for clinical documentation specialists to clinically validate the diagnosis if the standards are not present in the medical record. ASPEN presents six traits for diagnosis. According to an article in Wound Management & Prevention, they are:

• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation that may sometimes mask weight loss and diminished functional status as measured by hand grip strength

Additionally, according to the ACDIS Pocket Guide, the three milieus include acute disease/injury, chronic disease, and social factors. Note that ASPEN standards only denote severe from non-severe malnutrition and don’t include mild or moderate malnutrition criteria. For a full analysis of ASPEN criteria, read this article from ACP Hospitalist.

In addition to ASPEN criteria, there is also another criteria set called the Global Leadership Initiative on Malnutrition (GLIM). It defines malnutrition based on five diagnostic areas, which include three clinical findings and two etiologies. The clinical findings are weight loss percentage, low body mass index (BMI), and decreased muscle mass. The etiologies are reduced nutritional intake and inflammation.

Under GLIM criteria, malnutrition degree can be categorized as moderate to severe. It is significant to note that GLIM criteria, with the exception of BMI, is more closely aligned with severe malnutrition, and therefore, more likely for clinical validation acceptance. Also, GLIM malnutrition is based on one clinical finding and two etiologies.

Too often, clinical documentation specialists must clinically validate a diagnosis of severe PCM that has been based solely on an albumin or pre-albumin level. Historically, that is how malnutrition was diagnosed.  It was prevalent in medical, nursing, and nutrition manuals for years, and may explain why some providers still view hypoalbuminemia as an indicator for severe malnutrition. .

In 2013, serum albumin and pre-albumin were found to not be appropriate indicators of malnutrition, but some individuals aren’t aware of this finding. Providers remain confused when there are vague malnutrition signs, so turning to albumin and pre-albumin levels seems, to them, the most logical way to diagnose the malnourishment. Rather, these hepatoproteins indicate the severity of inflammation in the body more than nutritional status, according to the article in Wound Management & Prevention.

Although GLIM criteria utilizes these biomarkers to indicate inflammation, they alone are not sufficient to support severe malnutrition diagnoses. Hence, educating providers on complete ASPEN and/or GLIM guidelines can erase the confusion associated with diagnosing malnutrition.

Another important area to consider is the treatment being administered. Oral, enteral, or parenteral supplementation will be needed as well as nutritional consults, calorie counts, and intake monitoring. These actions will validate that severe malnutrition is clearly present as well as the necessary clinical indicators.

Physical exam documentation should include relevant descriptions such as muscle wasting, fat pad wasting, and temporal wasting. All these descriptions, along with other suitable indicators and treatment, may prevent clinical validation denials or the need for a clinical validation query.

According to an article in CDI Strategies, an OIG audit found hospitals owed Medicare $1 billion for incorrectly reported severe malnutrition diagnoses. It would be beneficial for all concerned to be on the same page. As mentioned previously, if the OIG was vague on what guidelines they were following to substantiate severe malnutrition, facilities would have a difficult time clinically supporting the diagnosis because they do not have appropriate guidelines to direct them. If the OIG uses one set of standards, and a facility uses a different set, then denial is inevitable.

Likewise, given the gaps in ASPEN criteria, what would stop the OIG, hypothetically, from taking the stance that ASPEN is not quite up to par? Perhaps a (severe) malnutrition summit is needed with the Cooperating Parties to determine a new malnutrition criterion that everyone can agree upon. In the meantime, ASPEN and GLIM are the most widely used and may be the best criteria to follow.

Editor’s note: Hutcheson is a remote CDI specialist at Community Health Systems in Franklin, Tennessee. Contact her at brandi_hutcheson@chs.net. Opinions expressed are those of the author and do not necessarily reflect those of Community Health Systems, ACDIS, HCPro, or any of its subsidiaries. Hutcheson’s contributions to this article do not include any CHSPSC, LLC data, proprietary processes or other information.