TPE, OIG Audit Malnutrition as Secondary Diagnosis; MAC Keeps Criteria to Itself

So far, WellSpan Health’s malnutrition claims are surviving an audit by the Medicare administrative contractor (MAC) under Targeted Probe and Educate (TPE), CMS’s new medical review strategy. The MAC approved four as coded, with one downgraded from severe to moderate malnutrition. What’s troubling, however, is the MAC, Novitas Solutions, hasn’t explained how it decides whether the documentation supports the malnutrition diagnosis. Hospitals and physicians generally use the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria, although it’s considered subjective and not necessarily a guarantee the diagnosis will be accepted. That’s a frustration as various auditors take on malnutrition.

“Novitas didn’t define what criteria it might be using,” says Sherian Kelley, a nurse auditor at WellSpan, a health system in York, Pa. Its claims seem to be passing muster because the physician documentation is very descriptive. She was impressed when she went into a chart and found a physician note that came to life: “cachexia-appearing female, temporal muscle wasting, sunken eyes, large muscle mass loss throughout and muscle strength diminished due to overall weakness, perhaps 3 out of 5 uniform.”

“It was an excellent example of what physician documentation should include for physical characteristics of malnutrition,” Kelley says.

With or without ASPEN, documentation will be the saving grace as more auditors put malnutrition under the microscope. The HHS Office of Inspector General added severe malnutrition to its Work Plan in January 2018, and Medicare Advantage plans have been denying a fair amount of malnutrition secondary diagnoses.

Malnutrition Is a Target of Medicare Advantage Plans

Medicare Advantage plans are auditing malnutrition as a secondary diagnosis. Here are two examples of denials received by WellSpan Health in York, Pa., says Nurse Auditor Sherian Kelley. Contact her at skelley@wellspan.org.

◆ A 57-year-old patient who had a history of chronic obstructive pulmonary disease presented to the hospital with complaints of shortness of breath, cough and wheezing. The patient reported weight loss but denied nausea, vomiting or diarrhea. She was alert and in moderate distress. The physician documented that she appeared cachectic. There were no peripheral edema notes and her breath sounds were diminished with wheezes and retractions. She was placed on a 2 gram sodium diet with fluid restriction. The patient underwent nutritional evaluation with findings of weight loss as well as significant loss of muscle and fat. The auditor said the services provided to the patient were inconsistent with care that would be required to treat a patient with severe malnutrition. There was no documentation of initiated tube feedings, total parenteral nutrition or administration of IV albumin. As a result, E43 (unspecified severe protein calorie malnutrition) was deleted as an additional diagnosis. The denial noted that even though the patient had clinical factors for malnutrition, there wasn’t an intensity of service associated with the diagnosis. WellSpan’s appeal was denied.

◆A 63-year-old patient was admitted in respiratory distress and unresponsive. The auditor recommended removal of E43 due to a lack of clinical evidence and recoded it to E46 (unspecified protein calorie malnutrition). WellSpan disagreed and appealed because the diagnosis was supported with severe muscle loss and body fat depletion, percutaneous endoscopic gastrostomy (PEG) tube placement, feedings, and low albumin and total protein levels. The payer denied the appeal on clinical validation, citing American Society for Parenteral and Enteral Nutrition (ASPEN) and World Health Organization criteria. WellSpan appealed, including numerous clinical findings for severe malnutrition. The appeal included the patient’s BMI of 17.3, chronic illness with severe muscle loss and body fat depletion, tube feedings, PEG placed and refeeding syndrome with low phosphorous, low potassium and low magnesium. The patient’s total protein was 4.6 and albumin was 2.5, and her weight had dropped to 103.39 pounds. The physician documented severe protein malnutrition. Even with all the clinical support, the auditor denied the appeal. That came as a surprise, Kelley says. “It shows how difficult a diagnosis it is to come to terms with” and how auditors sometimes downcode claims even when the documentation is loaded with evidence.

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