Severe Malnutrition Contributes to Claim Denials

Mounting evidence suggests that denial of claims is often based on a secondary diagnosis of severe malnutrition.

Denials by inpatients in hospital continue at breakneck speed. From a Health Information Management Coding and Clinical Documentation Integrity (CDI) perspective, there is compelling evidence for a pattern of denied claims with a primary or secondary diagnosis of sepsis, a primary or secondary diagnosis of acute respiratory failure, and denied requests for inpatient hospitalization with secondary diagnosis severe malnutrition. How do we deal with these rejections and how do we react to them?

Finding the root cause of denial and then finding solutions is the direction we should be taking; both will improve compliance and provide accurate data on patient severity and reimbursement. When it comes to denying a diagnosis of malnutrition, we’ve seen an additional focus on severe, moderate, and even mild malnutrition. These are represented by E43 ICD-10 CM codes Unspecified severe protein-calorie malnutrition, E44.0 Moderate protein-calorie malnutritionand E44.1 Mild protein-calorie malnutrition. The specific codes can affect the MS-DRG payment and can also affect the payment under Risk Adjustment, Hierarchical Condition Categories.

With all the documentation details and clinical criteria floating around, it can be overwhelming. The first thing you need to do is create a tracking log or tool for all your clinical denials and also your coding denials (if they occur). At least Excel spreadsheets work fine. In your tracking log, make sure to capture patient identifiers such as medical record number, discharge date, and patient name. List the denied diagnosis as well as the ICD-10-CM code and the payer. Next, add columns for various items or diagnostic criteria that led to the payer’s rejection (e.g., “conflicting documentation”, “absence of clinical indicators”, laboratory values ​​- normal/abnormal, etc.), and then add also add your own verification items. This log provides great information and helps spot trends and patterns.

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Let’s not confuse the criteria published by InterQual, Milliman and MCG (Clinical Guidelines) as these are mainly used to determine hospital admission status, level of care and medical need of care. All of these clinical criteria remain somewhat fluid and are constantly evolving as the world of medicine continues to expand in our digital age, leading to improvements in patient care and outcomes.

In addition, we have the European Society for Clinical Nutrition and Metabolism, the Latin American Nutritional Federation, and the Parenteral and Enteral Nutrition Society of Asia publishing the Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus have Report From the Global Clinical Nutrition Community,” in the Journal of Parenteral and Enteral Nutrition. In addition, the American Society for Parenteral and Enteral Nutrition criteria for acute care malnutrition were used. There is a great deal of information on diagnosing malnutrition. (You can visit their websites and get details on the clinical criteria aspects.)

Several resources and information on diagnostic coding for malnutrition have also been published, including the Official ICD-10-CM Guidelines for Coding and Reporting and the American Hospital Association Coding Clinic for ICD-10-CM/PCS. Every programmer must read and follow these two resources.

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Of course, clinical documentation is certainly key and is at the heart of most denials, but where there is conflicting, conflicting, incomplete or missing documentation, we must seek clarification from the provider, adhering to the 2019 AHIMA/ACDIS Practice Brief However, the issue of vendor co-signing on a nutrition label was identified with some refusals to pay. I’ve always wondered about this practice of having a co-signature on a nutritional label as the sole source of code assignment for that specific diagnosis.

The individual responsible for determining the diagnosis used for the code assignment is the treating physician/provider who is licensed by the State Medical Association and licensed by the Centers for Medicare & Medicaid Services (CMS). However, considering the sphere of activity of nutritionists, questions arise. Can the nutritionist make a diagnosis? Does co-signing mean that the provider agrees with the diagnosis stated on the nutritional screening, assessment, or notes?

Does this bypass the actual diagnosis of the condition by the provider licensed to do so? Is this co-signature sufficient to replace the actual healthcare provider documenting their own assessment for a malnutrition diagnosis? Well, many payers do not consider the malnutrition diagnosis with a co-signature on a nutrition sheet to be sufficient only Documentation support for the ICD-10-CM code assignment for malnutrition, and I agree.

I have also discussed this at the AHIMA level and they also agree that this practice does not provide a documented diagnosis from the doctor. If it is, or was, sufficient, we would have respiratory therapists documenting a diagnosis of respiratory failure and asking the provider to co-sign it for it to be coded. If this is sufficient or sufficient, we would have wound care diagnoses co-signed by the provider so that they would be coded and so on.

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Do not make the habit of abbreviating and/or circumventing the provider’s complete and accurate clinical documentation to encode a diagnosis.

Keep in mind that this diagnostic information must come from the CMS-approved provider who is legally responsible for making this diagnosis in the first place. If a dietary malnutrition diagnosis is co-signed by a provider, it is a good idea to initiate a confirmation query and obtain documentation from the provider. Have a conversation with the patient care team and CDI staff. Next, I would recommend having a written policy that includes guidance for both coding and CDI to ask questions if there is only a co-signature on dietary advice, respiratory therapy, wound care, etc. This could be a helpful step in reducing denial, including for malnutrition and other denials.

So don’t let the rejections get you down. Be proactive instead of reactive and look for the root cause and the best ethical and compliant solutions!

And at the end of the day: “Do the right thing!”


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