Malnutrition: Will the OIG Be Coming to See You? All You Need to Know and More

Transcription

1 Malnutrition: Will the OIG Be Coming to See You? All You Need to Know and More Vaughn Matacale, MD, CCDS Director, Physician Advisors Vidant Health Greenville, NC Kristen Gonzalez, MHA, RHIA Senior HIMS Administrator Vidant Health Greenville, NC This is the Full Title of a Session Shelby Humphreys, RHIA Corporate Director, Coding and CDI Vidant Health Greenville, NC 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Recognize components of the OIG audit process Describe the importance of clinical guidelines and definitions to support documentation and coding of malnutrition Discuss current coding guidelines and Coding Clinics that are relevant to compliant coding of malnutrition Explain the clinical implications and impact of diagnosing and treating malnutrition 2

3 Introduction 3

4 Vidant Health 8 hospitals (3 CAHs) 1,512 all Vidant hospitals 974 Vidant Medical Center Affiliated medical school 1,000+ providers 64,388 admissions 46,544 surgeries 5 physician advisors Over 30 IP coders and 15 CDSs Over 36 quality staff 4

5 OIG Letter of Engagement 5

6 Rationale for Performing Audit 6

7 Letter of Intent OIG Intent to audit inpatient claims with diagnosis code 261 (nutritional marasmus) or 262 (other severe protein calorie malnutrition) Objective was to determine compliance with Medicare regulations Period spanning January 2013 June

8 Kwashiorkor Audits Between 2014 and 2016, OIG published 25 reports on incorrect use of ICD 9 CM code 260 (Kwashiorkor) Dates of service span CY Overpayments of $6,030,135 identified Coding classification was unclear on use of code 260 Discrepancy between alpha and tabular index Alpha included Kwashiorkor, Malnutrition (calorie) malignant, Malnutrition (calorie) protein, Protein deficiency, Protein malnutrition Tabular listed only Kwashiorkor Coding software led to incorrect code assignment Recent report estimates total loss of $102 million during CY related to Kwashiorkor coding CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor 8

9 Flawed Audit Rationale OIG suggests that the rationale for incorrect billing of code 260 (Kwashiorkor) could have caused hospitals to incorrectly assign codes 261 and 262 Code 260 (Kwashiorkor) does not include protein malnutrition Clarified by AHA Coding Clinic Q Code 260, Kwashiorkor, is not appropriate since the provider did not specifically document this condition. Codes 261 (Nutritional marasmus) does includes severe malnutrition NOS Confirmed by AHA Coding Clinic Q If provider documentation indicates that the malnutrition has progressed from moderate to severe, assign code 261, Nutritional Marasmus, for Severe Malnutrition. 9

10 Why Us? Malnutrition Incidence Rank % of Patients With Malnutrition Volume Rank # of Malnutrition Cases FY14 #58/123 FY15 #14/123 FY16 #22/123 FY14 #19/123 FY15 #7/123 FY16 #8/123 *Among Vizient Academic Medical Centers 10

11 Vidant s Malnutrition Work Training: Identify and Train Subject Matter Expert Ashley Strickland, RDN, LDN, CNSC Subject matter expert competency Training: Vidant Medical Center Clinical dietitians Provider, pharmacists, CDI specialists Training: Other Regional and community dietitians Dietetic interns, home health agencies, case management Order entry considerations dietitian consults Modifications to dietitian documentation for clarification and specificity Education for coding/cdi teams ASPEN criteria Improved query structure clinical indicators and dietitian recommendation 11

12 Education: Coding and CDI Teams External consultant education Dietitian in service with existing coders Coding academy for new coder staff Articles for coder monthly focused education time CDS orientation and preceptor for new CDSs CDS meeting education for existing CDSs Pilot program CDS presentation Dietitian presentation at joint CDS and coder meeting ASPEN criteria education and references during CDS orientation Doc tips ASPEN material on shared drive 12

13 Vidant Audit 13

14 OIG Timeline of Events Oct OIG intent to audit letter received Nov Medical records sent Nov OIG on site visit (5 days) 2016 Apr OIG review results received May VMC submits rebuttal documents Jun OIG on site visit for case discussion (5 days) Oct OIG draft report issued to VMC Dec VMC submits response to OIG draft report Jan OIG final report published to OIG website Mar MAC demand letter received Apr 1 st level appeal submitted to MAC Jun 1 st level appeal determination received Aug Revised demand letter received Oct Recoupment occurs Dec 2 nd level appeal to QIC submitted Feb QIC letter received delayed decision 14

15 OIG Audit Experience Initial on site visit with OIG (Nov 2015) Four auditors on site for 5 days Lead auditor with experience in past kwashiorkor reviews Entrance/exit conferences Representation from legal, compliance, billing, HIMS, physician advisor teams Process interviews conducted Coding CDI Billing No reviews of cases during on site 15

16 OIG Audit Experience Records submitted by due date OIG contracts with outside review group (Maximus) Significant delays in audit completion Maximus results received late April 2016 Vidant performs immediate review of findings to prepare for any appeal opportunities On site case discussion offered by OIG Week of June 6, 2016 Case by case rebuttals by internal interdisciplinary team No intention of overturn by OIG auditors No opportunity to rebut directly to Maximus review team 16

17 OIG Audit Experience (OIG to MAC) Formal rebuttal to pending OIG final report underway (summer to fall 2016) OIG draft report shared and reviewed by Vidant Interdisciplinary team, legal, and compliance involved Formal statement submitted OIG final report published in January st level appeal prep underway Vidant waits for demand letter from MAC Discussions with CMS action official Contact made with PGBA representative Demand letter received (March 2017) Validation of information in letter Extrapolation amount verified 17

18 OIG Audit Experience (MAC to QIC) Appeal Activity 1 st level appeal filed with PGBA via standard request for redetermination protocol with MAC (April 2017) Results received timely Corrections required to demand letter extrapolation amount 1 st level appeal results (June 2017) 2 nd level appeal approach (Fall 2017) Review of existing 1 st level appeal Packet Modification of letter of intent to appeal, record detail, packet structure Submitted mid Dec 2017 Appeal File Submission One file containing: Main reconsideration request letter Request for reconsideration form Reconsideration listing of patients Prior audit findings Appeal packets (separate files for each patient) References used in appeal statements Main reconsideration request letter Case specific appeal letter Any physician queries Excerpts from medical record with direct support for clinical decision making and coding References pertinent to the case (coding guidelines, CMS guidance, ASPEN, AHA Coding Clinics) Full medical record 18

19 Audit Results and Analysis 19

20 20

21 OIG Audit Findings Vidant Medical Center 89% error rate Estimated overpayment for audit $401,971 Extrapolated overpayment $1.4 million Other audit 98% error rate Estimated overpayment $463,619 Extrapolated overpayment $1.28 million 21

22 OIG Audit Findings NEXT GOLD MINE DISCOVERED OIG 2018 Work Plan includes expansion of these audits nationwide Are you next? 22

23 Denial Rationale Breakdown Coding denials 45 claims Code 261 (Nutritional marasmus) was submitted, but the patient did not have nutritional marasmus The patient had malnutrition, but it was not treated enough or did not impact the stay enough to be reported as a diagnosis The patient had malnutrition but it was due to or an integral part of another condition and should not be separately reported as a diagnosis Clinical validation denials 44 claims The patient did not have malnutrition in any form The patient had a form of malnutrition, but not the type of malnutrition that was coded 23

24 Denial Rationale Frequency Rationale Category Primary Cases Total Cases The patient had malnutrition, but it was not treated enough or did not impact the stay enough to be reported as a diagnosis Coding The patient did not have malnutrition in any form Clinical Validation Code 261 (Nutritional marasmus) was submitted, but the patient did not have nutritional marasmus Coding 4 22 The patient had a form of malnutrition, but not the type of malnutrition that was coded Clinical Validation The patient had malnutrition but it was due to or an integral part of another condition and should not be separately reported as a diagnosis Coding

25 Malnutrition Not Treated or Impactful Enough Reporting additional diagnoses For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treatment; or Diagnostic procedures; or Extended length of hospital stay; or Increased nursing care and/or monitoring 25

26 Case Example: Not Treated Enough DENIAL RATIONALE Did not meet Medicare coverage criteria as billed with diagnosis code 261 (Nutritional marasmus). She had a chronic PEG tube. There was no new intervention, no new treatment beyond using the established PEG, and no impact on the length of stay. Criteria has not been met for the inclusion of marasmus as a secondary diagnosis. The focus of care was on hypoglycemia. CLINICAL BACKGROUND Pt with DM, CVA, Dysphagia, and PEG. Weight from 150 lbs to 111 lbs. Not eating well, not taking supplemental tube feeds. PE: Cachectic, thin, frail. Dietitian eval: severe malnutrition. Less than 75% of estimated energy needs for greater than a month, severe loss of subcutaneous fat in the triceps region, weight loss of 14%/6mo. Documented by MD as severe malnutrition in discharge summary. 26

27 Case Example: Not Treated Enough Clinical evaluation; or Reportability Standards This patient underwent a nutritional consult on 4/23/15 in which the nutritionist stated the patient met criteria for severe malnutrition in the setting of chronic illness based on energy < 75% of estimated energy needs for > 1 month along with severe loss of subcutaneous fat in the triceps region and a 67% weight loss over the past 2 years Therapeutic treatment; or In the H&P the physician documented the patient to have malnutrition with a documented weight loss of 14% in 6 months (wt. 11/4/14 was 55.6 kg with wt. 4/22/15 at kg) PEG feedings with recommendations Medication changes for appetite stimulation Diagnostic procedures; or Extended LOS; or Increased nursing care and/or monitoring Monitoring performed by dietetics team 27

28 AHA Letter of Support Neither the ICD 9 CM classification, the ICD 9 CM Official Guidelines for Coding and Reporting, nor Coding Clinic for ICD 9 CM specify a required level of treatment to warrant code assignment for diagnosis code 261 or any other diagnosis code as long as the condition meets the definition of a reportable diagnosis. As stated in the ICD 9 CM Official Guidelines for Coding and Reporting: For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. (Reference: Official Guidelines 2011, page 91, and 2002, page 48) 28

29 Patient Did Not Have Any Form of Malnutrition Confusion around basis for denials Clinical criteria, if any, used by reviewer was not disclosed OIG didn t know either CMS has not adopted a particular clinical guideline for evaluation, identification, and diagnosis of malnutrition CMS has not published any clarifying guidance on the use of 261 and 262 What are hospitals to do in absence of published guidance? 29

30 Case Example: Without Any Form of Malnutrition DENIAL RATIONALE The patient was admitted due to diarrhea. Management was focused on diarrhea with colonoscopy and stool studies. She was provided dietary support consistent with poor intake and dialysis but not specific to her nutrition state. Hospitalization was a consequence of her diarrhea and her nutrition state did not complicate the course. She was made nothing by mouth during her stay and no intervention was done to address the nutrition. Nutrition should not be part of the secondary diagnosis. CLINICAL BACKGROUND 67 yo. Admitted with fall and weakness, has diabetes, and ESRD (end stage renal disease) status post renal transplant with rejection. She was recently discharged for failure to thrive, started back on dialysis. Complained of diarrhea for several weeks. PE: cachectic with BMI of Patient was noted to have a 10 lb weight loss, consuming only 50% of meals. Nutrition focused physical exam: severe muscle depletion in the temporalis, clavicle, and interosseous regions. The patient was continued on Megace. Had hypokalemia, hypomagnesemia, and hypophosphatemia, concerning for refeeding syndrome. Monitored and repleted. Treated with high calorie nutritional supplements, vitamin and minerals, electrolyte supplements. PEG was considered but declined at that time. 30

31 Case Example: Without Any Form of Malnutrition ASPEN AND Severe Malnutrition Criteria Met in the Context of Chronic Illness: 2 of 6 Required for the Diagnosis of Severe Malnutrition Category Criteria Present Documentation Weight Loss >5% over 1 month >7.5% over 3 months >10% over 6 months >20% over 1 year Energy Intake Body Fat 75% of estimated energy requirement for 1 month Severe Depletion Yes Muscle Mass Severe Depletion Yes Fluid Accumulation Grip Strength Severe Reduced for Age/Gender Pt consuming less than 75% of energy needs for greater than 1 month RDN notes 11/20/14; 11/24/14 Severe muscle wasting assessed in the temporalis, clavicles, and interosseous muscles RDN notes 11/20/14; 11/24/14 31

32 Coding Denials The patient had malnutrition but it was due to or an integral part of another condition and should not be separately reported as a diagnosis Section I. A. 6. of the ICD 9 CM Official Guidelines for Coding and Reporting states: Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD 9 CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a use additional code note at the etiology code, and a code first note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.1 No published direction from UHDDS or AHA Coding Clinic that malnutrition is integral to other disease processes and should not be reported separately 32

33 Coding Denials The patient had a form of malnutrition but not the type of malnutrition that was reported Reviewers claimed that another code for malnutrition was more appropriate Suggestion to review codes to unspecified or lower degree of specificity ICD 9 CM Official Guidelines for Coding and Reporting dictate that diagnoses must be coded to the highest degree of specificity. CMS also clarified this requirement, stating: The physician should code the ICD 9 CM code that provides the highest degree of accuracy and completeness. In the context of ICD 9 CM coding, the highest degree of specificity refers to assigning the most precise ICD 9 CM code that most fully explains the narrative description of the symptom or diagnosis. 33

34 Coding Denials Code 261 (Nutritional marasmus) was submitted, but the patient did not have nutritional marasmus The OIG failed to recognize and acknowledge that code 261 (Nutritional marasmus) includes additional malnutrition conditions: An example of direction for coding severe malnutrition with code 261 can be found in AHA Coding Clinic, Third Quarter 2012, Page 10, effective with discharges September 15, 2012, which states: If provider documentation indicates that the malnutrition has progressed from moderate to severe, assign code 261, Nutritional Marasmus, for Severe Malnutrition. 34

35 Clinical Perspective and Directing Guidance 35

36 Clinical Impact of Identifying and Treating Malnutrition 1 in 3 patients enter a hospital malnourished Malnourished patients: 2x more likely to develop a pressure ulcer in a hospital Hospitalized an average of 2 days longer than those screened and treated early Comprise 45% of patients that fall in a hospital Have 3x the risk for surgical site infection Benefits of nutrition intervention: 25% reduction in pressure ulcer incidence 28% decrease in avoidable readmissions 14% fewer overall complications ~2 day reduction in average length of stay Recommended further reading: Tappenden KA, Quantara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Parenter Enteral Nutr. 2013;37(4): The Facts on Malnutrition. Available from: Accessed January 13,

37 Impact of Malnutrition Study at VMC Defining the Impact of Malnutrition on the GI Surgical Patient With a Standardized Evaluation C. Mosquera, N.J. Koutlas, K. Chandra, N.A. Vohra, E.E. Zervos, A. Strickland, F.L. Timothy 490 patients who underwent abdominal surgical procedures on surgical oncology unit at VMC from June 2013 to March patients (19.0%) were diagnosed with severe or moderate malnutrition by a dietitian Malnutrition was associated with: Longer LOS (13.3 vs. 7.4 days) P < Increased cost ($45,433 vs. $24,658) P <

38 Joint Commission Stance on Malnutrition In 1995 The Joint Commission partnered with ASPEN, the American Society of Clinical Nutrition (now the American Society of Nutrition [ASN]), and the American Dietetic Association (now the Academy of Nutrition and Dietetics) to develop survey accreditation standards that emphasized interdisciplinary delivery of nutrition care and required that all patients have a nutrition screening within 24 hours of admission. 38

39 Joint Commission Stance on Malnutrition The Joint Commission Journal on Quality and Patient Safety Forum Addressing Disease Related Malnutrition in Hospitalized Patients: A Call for a National Goal October 2015, Volume 41, Number 10 39

40 Joint Commission Stance on Malnutrition Actions to Take 1. Each clinician on the interdisciplinary care team should participate in the execution of the nutrition care plan. Teams should include a physician, dietitian, nurse, and pharmacist, at a minimum. 2. Develop systems to quickly diagnose all malnourished patients and those at risk. If malnutrition is present, it should be included as one of the patient s coded diagnoses. 3. Develop nutrition care plans in a timely fashion and implement comprehensive nutrition interventions (optimally within 48 hours of identification of the malnourished patient). 40

41 CMS IPPS Final Rule May 2015 We believe that RDs (clarified as qualified nutrition professional) are the professionals who are best qualified to assess a patient s nutritional status and to design and implement a nutritional treatment plan in consultation with the patient s interdisciplinary care team. In order for the patient to receive timely nutritional care the RD must be viewed as an integral member of the hospital interdisciplinary care team, one who, as the team s clinical nutrition expert, is responsible for the patient s nutritional diagnosis and treatment in light of the patient s medical diagnosis. All patient diets including therapeutic diets must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian hospitals that choose to grant these privileges to RDs may achieve a higher quality of care for their patients by allowing these professional to fully and efficiently function as important members of the hospital patient care team in the role for which they were trained. 41

42 IPPS Final Rule 2018 Proposed VBP Measures National Quality Forum (NQF) Number NQF #3087 NQF #3088 NQF #3089 NQF #3090 Centers for Medicare & Medicaid Services (CMS) Number MUC MUC MUC MUC Electronic Clinical Quality Measure (ecqm) Completion of a Malnutrition Screening Within 24 Hours of Admission Completion of a Nutrition Assessment for Patients Identified as At Risk for Malnutrition Within 24 Hours of a Malnutrition Screening Nutrition Care Plan for Patients Identified as Malnourished After a Completed Nutrition Assessment Appropriate Documentation of a Malnutrition Diagnosis 42

43 Appropriate Documentation of Malnutrition Diagnosis Measure The Appropriate Documentation of a Malnutrition Diagnosis measure (MUC16 344) assesses whether patients age 65 years and older, who are found to be malnourished on the nutrition assessment, have adequate documentation of a malnutrition diagnosis in their medical record. This measure is important because there is often a disconnect between screening for malnutrition and documentation of a diagnosis of malnutrition, which is necessary for appropriate follow up after hospital discharge. Data analyzed from the Healthcare Cost and Utilization Project (HCUP), a nationally representative data set describing U.S. hospital discharges, indicated that approximately 3.2% of hospital discharges in 2010 included malnutrition as a diagnosis. However, this same research article notes that the prevalence of a malnutrition diagnosis may be significantly higher as past researchers, using validated screening tools, indicate a significantly higher prevalence of undiagnosed malnutrition in the hospital, ranging from 33% to 54%. 43

44 Joint Commission Comments The Joint Commission appreciates the opportunity to submit comments in support of inclusion of this suite of malnutrition measures in the Hospital Inpatient Quality Reporting Program (MUC16 294, MUC16 296, MUC16 344, and MUC16 372) addressing malnutrition developed by Avalere and the Academy of Nutrition and Dietetics. Joint Commission standards have long reflected the importance of nutrition screening, assessment of at risk hospitalized patients, diagnosis of malnutrition, and appropriate intervention. Malnutrition is an ongoing healthcare issue with demonstrated impacts on patient outcomes. The Joint Commission welcomes the advent of performance measures to quantify the degree to which these best practices are carried out. 44

45 Summary 45

46 Where Do We Stand Today? Appeal status Clinical initiatives have continued Coding education and compliance remains a high priority 46

47 Key Points and Takeaways Develop and maintain a multidisciplinary approach to diagnosing and coding malnutrition Maintain a current and consistent definition of malnutrition Educate coding and clinical staff Maintain coding compliance and consistency for malnutrition Prepare for the long haul if you are audited DO WHAT IS BEST FOR PATIENTS 47

48 Want More In Depth Information? ACDIS May 2016 presentation link (ACDIS members only): conference track 1 malnutrition pairing your dietitians diagnose documentand capture 48

49 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 49