Coding for Malnutrition-A Success Story

Objectives

Identity steps to build a Malnutrition Documentation Program

Learn how coordination and teamwork between medical staff, nutrition, coding and decision support can benefit patient care.

See examples of data, monitoring systems and processes used to properly code for malnutrition

Understand how DRG reimbursement works

Learn which ICD-9 codes have the potential to impact reimbursement

Identify the positive outcomes on patients, staff and the facility

What effect does correct coding have?

Coding needs to reflect the acuity of the patientHaving accurate coding results in appropriate DRG and APR-

DRG assignmentMost DRG’s have 3 levels. With major

complication/comorbidity, with regular complication/comorbidity or neither

The sicker the patient the better the potential DRG reimbursement. However the codes have to be there.

APR-DRG have a severity index and a risk of mortality score that is used when looking at the intensity of the services needed by the patient. This is basically helping to risk adjust your patient.

Where to begin?

We were already working with consultants from Don Miller and Associates (DM & A, Inc.) on improving Press Ganey scores.

Several Success coaches (Registered Dietitians) through DM & A, Inc. had developed a Malnutrition Documentation Program (MDP) and had been successful at several other facilities improving documentation and potential DRG reimbursement.

Consultants recommended a chart audit be performed to determine if improved documentation was needed at WVU Healthcare.

Spoke to administration/CFO to get permission for consultants to perform chart review to determine potential for increased reimbursement

Where to begin?

Next steps:Determine what process is currently being used for malnutrition documentation

Speak with Decision Support/Finance to get data on Malnutrition codes billed during the previous year and how often a DRG was impacted

Once administration approved for the chart audit we had to determine how many charts would be audited to determine any potential benefit for our patients and facility

RED indicates companies that provide additional revenue due to DRG moves (bolded provide the most)

DRG based payers 68%, Other payers 32%

Blue Cross/Blue Shield Commercial Medicaid Medicaid MC Medicare Medicare Advantage Other Gov’t Self Pay

Determine payer mix to determine impact of malnutrition coding on your population

Complete a chart audit to determine any potential areas of improvement

150 charts selected-(adult acute care, >18 years old and non-pregnant)

50 with Nutrition consults 50 with Nursing high risk notifications (HRN) 25 with malnutrition ICD-9 codes on file 25 with none of the above

Chart Review-charts pulled January-April (specific sample chosen)

Previous Malnut Dx (Y//N)

New / Add. Malnut. Dx

New Malnut.Dx Impact DRG

(MCC/CC/NEITHER)

Change (+/-) ReimbursementNew Malnut Dx

$151,569.05

783.7,783.21 262 MCC $4,478.40

N 262 MCC $5,800.47

N 262; 783.22 MCC $6,107.91

263.9 262 MCC $21,037.99

263.9 261 MCC $21,037.99

783.7 262 MCC $5,987.65

N 261; 783.22 MCC $8,066.36

N 261; 783.22 MCC $8,066.36

N 262 MCC $3,227.96

N 261 MCC $40,714.04

N 261 MCC $7,411.68

N 263.8; 783.22 MCC $3,371.32

Y 260 MCC $3,371.32

N 260 MCC $12,889.59

Inpatient in house for pneumonia. Potential DRGs are:

DRG Description Weight

193 SIMPLE PNEUMONIA & PLEURISY W MCC 1.4948

194 SIMPLE PNEUMONIA & PLEURISY W CC 1.0026

195 SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC 0.7037

Accurately documenting “Other Severe Protein-Calorie Malnutrition” based on the conditions presented by the patient change the DRG from 193 to 195 (thus doubling your potential receipts).

Results of Chart Review = to actual numbers??

12 charts out of the 14 eligible for improved documentation and potential increased reimbursement had either a dietitian consult or HRN to nutrition which constituted 8% of the charts reviewed

If we started documenting more cohesively/clearly and changed our processes only on those the Registered Dietitian saw there could be a significant potential increase in reimbursement

•Over the previous 4 months there were 2,494 consults/HRN’s. If 8% of these had the potential for improved documentation and could possibly move the DRG, we could potentially impact our reimbursement for the year by more than 100%.

Discuss findings with Administration

• Results of chart review and potential improved documentation resulting in potential additional reimbursement shared with Director of department, Assistant VP of Support Services, VP of Support Services and Decision Support

• Questions addressed at whether we could extrapolate the data and actually make the needed changes to obtain the needed documentation changes and estimated potential reimbursement

• Administration approved for the consultants to come in during the following year and teach us how to educate our staff on improved documentation for malnutrition based on a conservative estimation

Getting the right people involvedWho do we include in this process?

Department director Clinical Nutrition Manager Dietitians Physicians-hospitalists and specialists Decision support/Finance Medical records-coding/tracking EMR personnel Nurse managers VP of Quality

*At later stages: Med Exec and PNT committees for policy/practice changes and communication to staff

Right people/Right process Champion team members selected and brought together

in meetings to learn more about malnutrition documentation and how their involvement is key to our success

Current processes of documentation discussed and needed changes reviewed with all team members

Polices and procedures reviewed including current assessment and follow-up forms, screening process and NCP PES statements

Education process started to begin thinking differently about how we chart

Right people/Right process

Differences between coders criteria and dietitians charting noted

Reviewed ICD-9 codes specific to malnutrition and how often they were being documented

Information surfaced on how more cohesive and clear documentation for malnutrition can improve the hospital’s overall morbidity and mortality rates-the more conditions identified in the patient the better the risk adjustment to the hospital

• Correct coding is the key to a provider being properly reimbursed. To process insurance claims correctly, the patients diagnosis and treatment has to be coded properly. Coding involves taking the physicians notes from the visit and translating into the proper diagnosis codes for diagnosis and treatment codes for processing by the insurance carrier.

• The art in medical billing coding is understanding how to correctly determine and assign the proper codes, and insuring the ICD-9 diagnosis and CPT treatment codes match correctly for a provider. Otherwise the claim will be rejected by the insurance payer resulting in a time and labor intensive process of follow-up and claim resubmission.

• www.all-things-medical-billing.com/medical-billing-codes.html

International Classification of Diseases,Ninth Revision (ICD-9) The International Classification of Diseases (ICD) is designed to

promote international comparability in the collection, processing, classification, and presentation of mortality statistics.

This includes providing a format for reporting causes of death on the death certificate. The reported conditions are then translated into medical codes through use of the classification structure and the selection and modification rules contained in the applicable revision of the ICD, published by the World Health Organization. These coding rules improve the usefulness of mortality statistics by giving preference to certain categories, by consolidating conditions, and by systematically selecting a single cause of death from a reported sequence of conditions. The single selected cause for tabulation is called the underlying cause of death, and the other reported causes are the non-underlying causes of death. The combination of underlying and non-underlying causes is the multiple causes of death.

www.cdc.gov

Malnutrition related ICD-9 codesType of Comorbidity

associated with ICD-9 260 Kwashiorkor 261 Nutritional Marasmus 262 Other Severe Protein-Calorie

Malnutrition 263.0 Malnutrition of Moderate Degree 263.1 Malnutrition of Mild Degree 263.8 Other Protein-Calorie Malnutrition 263.9 Unspecified Protein-Calorie

Malnutrition 278.1 Morbid Obesity 799.4 Cachexia

MCCMCCMCCNoneNoneCCCCNoneCC

ICD-9 codes related to nutrition

ICD-9 Codes that potentially move DRG’s

Type of Comorbidity associated with ICD-9

260 Kwashiorkor 261 Nutritional Marasmus 262 Other Severe Protein-Calorie

Malnutrition 263.0 Malnutrition of Moderate Degree 263.1 Malnutrition of Mild Degree 263.8 Other Protein-Calorie Malnutrition 263.9 Unspecified Protein-Calorie

Malnutrition 278.1 Morbid Obesity 799.4 Cachexia

MCCMCCMCCNoneNoneCCCCNoneCC

ICD-9 codes related to nutrition

Next Steps:Determine charting methods to correctly capture information pertinent to coders

Helped physician’s correctly document malnutrition dx/ICD-9 terminology required by CMS

Coders need to receive signed documentation from the physician to code for that particular malnutrition dx

Aided coders in collecting information they previously had to search for in the patient charts

Created better communication for dietitians and physicians and allowed for the addition of order writing privileges protocol on those patients found to have a malnutrition dx

Completed pilot study on several services to determine effectiveness of process and areas of improvement needed.

A win-win for all!

Next Steps:

Consultants came for site visits 4 different times during the following year to help us with education, documentation and guidance

They helped us to continually update our information based on the latest research and improve our system

They were able to help us determine what worked best for our facility

They were also available via e-mail or phone conference for any questions that arose in between site visits

• At present, there is no gold standard for the definition of adult malnutrition in the medical literature, thus resulting in widespread confusion.  The original definition for malnutrition was based on the pediatric population from less-developed countries.1  By contrast, disease-related malnutrition that includes an inflammatory component is commonly observed in clinical practice settings.  The International Dietetics and Nutrition Terminology  has defined malnutrition as "Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting including starvation-related malnutrition, chronic disease-related malnutrition and acute disease or injury-related malnutrition."2

• www.eatright.org

Malnutrition in a hospital setting

• The diagnoses, codes, definitions and degrees of malnutrition have become more important to registered dietitians since 2007, when the Centers for Medicare and Medicaid Services revised the Hospital Inpatient Prospective Payment System to include 745 severity-adjusted, diagnosis-related groups. A part of this revision included increased payments for the care of patients whose physicians diagnosed their patients with severe malnutrition.3  Adding to the confusion, the codes of the Clinical Modification of the Ninth Revision of the International Classification of Diseases (ICD-9-CM) use the  terms marasmus and kwashiorkor that do not apply to patients seen in acute and chronic care in settings in developed countries.3

www.eatright.org

Malnutrition in a hospital setting

• One of the challenges facing registered dietitians is to identify patients who are or who may become malnourished and to determine the optimum nutrition intervention.

• www.eatright.org

• The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) have proposed new malnutrition codes to the National Center for Health and Vital Statistics for inclusion into the ICD-9/ICD-10 Codes System used in the United States.4 There is continuing discussion and reconciliation of the Academy/ASPEN proposal with the National Center for Health Statistics policies and procedures for code revisions acceptance. Readers are advised that based on reports of overuse or inappropriate use of the kwashiorkor diagnosis, the National Center for Health and Vital Statistics may issue some direction on use of existing malnutrition diagnosis codes during 2012.3

• www.eatright.org

Code DescriptionNo. of times

used StatusPre Program Monthly Avg

Avg During Program

260 Kwashiorkor 19 MCC 1.6 1.0261 Nutritional Marasmus 73 MCC 6.1 3.2

262Other Severe Protein-Calorie Malnutrition 102 MCC 8.5 52.3

263.0 Malnutrition Of Moderate Degree 74 None 6.2 29.7263.1 Malnutrition Of Mild Degree 19 None 1.6 5.5

263.2Arrested development following protein-calorie malnutrition 0 CC 0.0 0.0

263.8 Other Protein-Calorie Malnutrition 42 CC 3.5 1.8263.9 Unspecified Protein-Calorie Malnutrition 741 CC 61.8 49.8278.01 Morbid Obesity 602 None 50.2 84.3783.22 Underweight 3 None 0.3 0.8799.4 Cachexia 85 CC 7.1 18.0V85.0 Body Mass Index less than 19, adult 0 CC 0.0 25.2V85.4* Body Mass Index 40 and over, adult 395 CC 32.9 76.8

Number of discharges that had at least one of the above codes: 188.2 250.7

Number of discharges that had at least one of the above codes that's a CC or MCC 118.4 152.3

Total discharges during period (includes NB) 1,923.5 2,081.4

% of cases with a CC or MCC 6.2% 7.3%

What we learned...• Look at not only the

basic information we were taught but also become proficient at physical assessments to take into account skin, hair, nails, etc.

• Take the time needed to dig for needed information in order to best determine malnutrition.

• Learn how small changes can have a large effect on patient outcomes and the hospital’s bottom line.

What we learned...• The dietitians felt they became better clinicians through improved education and changing their practice

• The physician’s learned how correctly documenting for malnutrition can help with overall risk adjustment and have a direct impact on them

• The coders felt their jobs were made easier

What we learned...• Administration/Finance had a greater appreciation of dietitian’s services, our contribution to patient care and that we could be revenue generating

• The Malnutrition Documentation Team won a Quality Award from the hospital for all of our efforts and success

References:

www.eatright.org

www.all-things-medical-billing.com/medical-billing-codes.html

www.cdc.gov

www.ahrq.gov/qual/mortality/Hughessumm.pdf

Contact information for consultants:

Michelle Hoppman, RD, LRD, CDEExecutive Success Coach

DM&A, Inc.871 Bowsprit RoadChula Vista, CA 91914(716) 572-6502 Direct(619) 656-2100 Main(619) 656-1321 Faxmichelle.hoppman.dma@gmail.com www.chefdon.com 

Questions???