Office of Inspector General Reports on Hospital Inpatient Billing for Severe Malnutrition
Joint Statement from the Academy of Nutrition and Dietetics, the American Society for Parenteral and Enteral Nutrition, the American Society for Nutrition, and the Association of Clinical Documentation Integrity Specialists
August 17, 2020
On July 13, 2020, the Office of the Inspector General (OIG) under the Department of Health and Human Services released a report of its findings from an audit of FY16 and FY17 hospital inpatient claims to determine whether hospitals compiled with Medicare billing requirements when assigning severe malnutrition diagnosis codes. The OIG found that 173 of 200 claims reviewed did not correctly bill Medicare for severe malnutrition diagnosis codes (E41 and E43), resulting in estimated overpayments of $1 billion. The OIG recommended the Centers for Medicare & Medicaid Services (CMS) attempt to recover the overpayments.
The Academy of Nutrition and Dietetics (Academy), the American Society for Parenteral and Enteral Nutrition (ASPEN), the Association of Clinical Documentation Integrity Specialists (ACDIS), and the American Society for Nutrition (ASN) continue to be concerned about the lack of transparency around criteria used by both the OIG and CMS auditors in reviewing such claims. Despite efforts, CMS still has been unable to provide us with written policies and procedures for what they consider to be correct criteria for diagnosis and coding of severe malnutrition. Anecdotal reports from our members and review of some CMS auditor raise concerns about inappropriate use of criteria such as serum albumin. This task force has been actively collaborating for several years on efforts to help the U.S. Department of Health and Human Services, the OIG, and CMS understand the best practices for diagnosing, documenting, and coding for malnutrition. As characterized by experts in the field, these criteria have evolved appreciably over the past two decades, such that some historic indicators of malnutrition are now considered to lack validity. The task force intends to continue these efforts including providing a response to CMS about the OIG report.
As registered dietitian nutritionists and other clinical nutrition professionals are approached by their coding departments about the potential use of the GLM criteria in place of the Academy/ASPEN criteria, we refer them to our previous statement on the topic. Both sets of criteria represent consensus-based frameworks and we are currently undergoing validation testing. Until those studies are completed, we are not recommending one approach over the other.
As always, thorough documentation to support a diagnosis of malnutrition and the associated intervention(s) continues to be a critical component of clinical practice. The importance of comprehensive documentation with inclusion of specific and consistent criteria used to support malnutrition diagnosis cannot be overemphasized. Moreover, it is essential to outline the treatments and monitoring efforts related to the malnutrition diagnosis. Of greatest importance is establishing a process of collaboration with providers to ensure their documentation is consistent with the diagnosis and treatment plan. This can best be accomplished by ongoing competency training for all members of the health care team and clinical documentation improvement professionals.
We will continue to update our members as our efforts to deal with this issue move forward, share any added insight gained from OIG or CMS responses to our efforts, and keep you apprised of any important information impacting your practice.