Coding for MalnutritionA 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 patient
 Having accurate coding results in appropriate DRG and APR-
DRG assignment
 Most 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
Determine payer mix to determine impact of
malnutrition coding on your population
 RED indicates companies that provide additional revenue
due to DRG moves (bolded provide the most)
 DRG based payers 68%, Other payers 32%
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Blue Cross/Blue Shield
Commercial
Medicaid
Medicaid MC
Medicare
Medicare Advantage
Other Gov’t
Self Pay
Complete a chart audit to determine any
potential areas of improvement
Chart Review-charts pulled January-April (specific
sample chosen)
150 charts selected-(adult acute care, >18 years old and nonpregnant)
 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
Previous Malnut
Dx (Y//N)
New / Add.
Malnut. Dx
New Malnut.Dx Impact
DRG
(MCC/CC/NEITHER)
783.7,783.21
N
N
263.9
263.9
783.7
N
N
N
N
N
N
Y
N
262
262
262; 783.22
262
261
262
261; 783.22
261; 783.22
262
261
261
263.8; 783.22
260
260
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
MCC
Change (+/-)
Reimbursement
New Malnut Dx
$151,569.05
$4,478.40
$5,800.47
$6,107.91
$21,037.99
$21,037.99
$5,987.65
$8,066.36
$8,066.36
$3,227.96
$40,714.04
$7,411.68
$3,371.32
$3,371.32
$12,889.59
Sample Patient
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 involved
Who 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
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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
Importance of coding
• 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 codes
Type of Comorbidity
associated with ICD-9
260 Kwashiorkor
 MCC
261 Nutritional Marasmus
 MCC
262 Other Severe Protein-Calorie
 MCC
Malnutrition
 None
263.0 Malnutrition of Moderate Degree
 None
263.1 Malnutrition of Mild Degree
263.8 Other Protein-Calorie Malnutrition  CC
263.9 Unspecified Protein-Calorie
 CC
Malnutrition
 None
278.1 Morbid Obesity
 CC
799.4 Cachexia
ICD-9 codes related to nutrition
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ICD-9 Codes that potentially move DRG’s
Type of Comorbidity
associated with ICD-9
260 Kwashiorkor
 MCC
261 Nutritional Marasmus
 MCC
262 Other Severe Protein-Calorie
 MCC
Malnutrition
263.0 Malnutrition of Moderate Degree  None
 None
263.1 Malnutrition of Mild Degree
263.8 Other Protein-Calorie Malnutrition  CC
263.9 Unspecified Protein-Calorie
 CC
Malnutrition
 None
278.1 Morbid Obesity
 CC
799.4 Cachexia
ICD-9 codes related to nutrition
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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
Malnutrition in a hospital setting
• 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
Malnutrition in a hospital setting
• 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/ICD10 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
WVU Healthcare codes changes after improved documentation
Code
260
261
262
263.0
263.1
Description
Kwashiorkor
Nutritional Marasmus
Other Severe Protein-Calorie
Malnutrition
Malnutrition Of Moderate Degree
Malnutrition Of Mild Degree
Arrested development following proteincalorie malnutrition
Other Protein-Calorie Malnutrition
Unspecified Protein-Calorie Malnutrition
Morbid Obesity
Underweight
Cachexia
Body Mass Index less than 19, adult
Body Mass Index 40 and over, adult
No. of times
used Status
19 MCC
73 MCC
Pre Program Avg During
Monthly Avg
Program
1.6
1.0
6.1
3.2
102
74
19
MCC
None
None
8.5
6.2
1.6
52.3
29.7
5.5
0
42
741
602
3
85
0
395
CC
CC
CC
None
None
CC
CC
CC
0.0
3.5
61.8
50.2
0.3
7.1
0.0
32.9
0.0
1.8
49.8
84.3
0.8
18.0
25.2
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
1,923.5
2,081.4
6.2%
7.3%
263.2
263.8
263.9
278.01
783.22
799.4
V85.0
V85.4*
Total discharges during period (includes NB)
% of cases with a CC or MCC
• 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.
Physical Assessment
• 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
• 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, CDE
Executive Success Coach
 DM&A, Inc.
871 Bowsprit Road
Chula Vista, CA 91914
(716) 572-6502 Direct
(619) 656-2100 Main
(619) 656-1321 Fax
michelle.hoppman.dma@gmail.com
www.chefdon.com
Questions???