7/21/2021 - In July 2020, the Office of the Inspector General (OIG) under the Department of Health and Human Services released a report of its findings from audits to determine whether hospitals complied with Medicare billing requirements when assigning severe malnutrition diagnosis codes. In that report the OIG recommended the Centers for Medicare & Medicaid Services (CMS) attempt to recover the overpayments.
In December 2020, members of the multiorganizational malnutrition diagnosis, documentation, and coding task force including the American Society for Parenteral and Enteral Nutrition (ASPEN), the Academy of Nutrition and Dietetics (Academy), the American Society for Clinical Documentation Integrity Specialists (ACDIS) and the American Society of Nutrition (ASN) met with members of the CMS Provider Compliance Division (CPI) expressing concerns about improper denials and the lack of transparency around criteria used by auditors in reviewing severe malnutrition claims.
As a follow up to the December meeting, task force members recently participated in a “listening session” with CMS-CPI members along with members of the Supplemental Medical Review Contractor who will be conducting the post OIG report supplemental review. In this session, task force members shared and expanded on the following key points from our previous communications:
- Misuse of antiquated malnutrition diagnostic approaches by CMS contractors (visceral proteins) as malnutrition indicators.
- Misapplication of current approaches that do have validity by CMS contractors – the requirement of a low body mass index in addition to standard nutrition assessment methodologies.
- Recommended use of the Academy/ASPEN malnutrition diagnostic methodology – based on well-known indicators reflecting nutrition issues and related to negative outcomes. Most hospitals in the US are using this approach with increasing evidence demonstrating its validity.
- According to the CMS 2014 Final Rule on Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction, the dietitian is the most qualified to provide this assessment, and the application of the expertise and time of a dietitian to provide an assessment should be sufficient for reporting the diagnosis. The dietitian works closely with the provider to assure alignment of the malnutrition diagnosis and that it is documented correctly in the electronic health record.
- Malnutrition treatment should begin with the least invasive method and include a stepwise approach for escalation. Treatment as prescribed by the dietitian or provider should be sufficient for reporting, which may vary from adjustment of oral diets to more aggressive nutrition interventions, such as enteral or parenteral nutrition.
While there is no specific timeline for the supplementary review, we will continue to engage with CMS and provide our expertise.
It is important for hospitals to continue to ensure a sound process is in place in light of the nationwide audit that CMS is planning. Our message to CMS and practitioners remains the same. These include:
- A multidisciplinary team approach for care
- Application of a uniform set of criteria
- Collaboration between dietitians, providers, clinical documentation integrity specialists, and coding specialists to ensure continuity of clinical care, documentation, and coding
- Documentation of the condition with appropriate specificity along with the criteria used for the diagnosis.
Further updates will be provided as new information is identified.