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Copyright Information 1 Copyright Information Copyright © 2013 HCPro, Inc. The “Malnutrition Coding and Documentation: Strategies to Implement a Compliant Query Process” webcast materials package is published by HCPro, Inc. For more information, please contact us at: 75 Sylvan Street, Suite A-101, Danvers, MA 01923. Attendance at the webcast is restricted to employees, consultants, and members of the medical staff of the Licensee. The webcast materials are intended solely for use in conjunction with the associated HCPro webcast. The Licensee may make copies of these materials for internal use by attendees of the webcast only. All such copies must bear the following legend: Dissemination of any information in these materials or the webcast to any party other than the Licensee or its employees is strictly prohibited. In our materials, we strive to provide our audience with useful and timely information. The live webcast will foll ow the enc lose d agen da. Occas iona lly, our spea kers w ill re fer to the enc lose d ma ter ia ls. We have noticed that non-HCPro webcast materials often follow the speakers’ presentations bullet-by-bullet and page-by-page. However, because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker’s entire presentation. The enclosed materials contain helpful resources, forms, crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future. Although every precaution has been taken in the preparation of these materials, the publisher and speaker assume no responsibility for errors or omissions, or for damages resulting from the use of the information contained herein. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro,,, Inc., is not affiliated in any yy way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks; the Accreditation Council for Graduate Medical Education, which owns the ACGME trademark; or the Accreditation Association for Ambulatory Health Care (AAAHC). 2 If you are not hearing music or you are experiencing any technical difficulties, please contact our help desk at 888-364-8804. We will begin shortly! 3 4 Presented by: James S. Kennedy, MD, CCS, is a managing director in the FTI healthcare group of FTI’s corporate finance practice and is based in Brentwood, Tenn., and Atlanta. His experience andtiildhiidhitld expertise includes physician and hospital leadership, healthcare systems improvement, ICD-9-CM and DRG documentation and coding compliance, and government relations. 5 Presented by: Joann A. Agin, RHIT, CCDS serves as regional manager, data quality at Carondelet Health in Kansas City, Mo. Her responsibilities include direct management of day-to-day coding, abtbstrac ting, an d c liilinica ldl documen ttitation improvement functions for both acute care facilities. Agin has years of experience with management and training of coding , utilization review/medical necessity, and clinical documentation improvement. She is a member of AHIMA and ACDIS. Agin organized and currently serves as chair of the Kansas City ACDIS chapter; she is also a member of the ACDIS Networking Leadershipp, Committee, an AHIMA-Approved ICD- 10-CM/PCS Trainer, and an AHIMA ICD-10 Ambassador. 6 Presented by: Mindy Hamilton, RD, LD, is a registered dietitian from Kansas City, MO. Hamilton started her career as a clinical dietitian and has served as clinical nutrition manager and assitistan tdit direc tor o fthff the foo d an d nu tititrition department for Carondelet Health. During her time with Carondelet, Hamilton and a team of registered dietitians and HIM coders implemented a malnutrition coding program that saw over $650K in reimbursement during its first two years. She currently is a project manager for the healthcare division of Perceptive Software. 7 Background INTEREST IN MALNUTRITION 8 Malnutrition Simple Definitions • Any nutritional imbalance – Overnutrition • Overweight, obesity, and morbid obesity – Undernutrition • Occurs along a continuum of inadequate intake and/or increased requirements, impaired absorption, altered transport, and altered nutrient utilization – Can be carbohydrates, fats, proteins, vitamins, minerals, or other unrecognized factors 9 Malnutrition Prevalence “UdUnder diagnosi s” • Pediatric • Adult hospitalization hospitalization – 1998: 23.5% – Acute – 2000: 20.4% • Severe: 1. 3% – 2003: 19. 1% • Moderate: 5.8% • Certain diseases • Mild: 17.4% – Pancreatic cancer: 85% • N755%None: 75.5% – Lung cancer: 13%–50% – Chronic – Head and neck cancer: • Severe: 5.1% 24%–88% • Moderate: 7.7% – GI cancer: 55%–80% • Mild: 14.5% – Stroke: 16%–49% • None: 72.8% – COPD: 25% Henricks, KM. Malnutrition in hospitalized pediatric patients. Current prevalence. Arch Pediatr Adolesc Med 1995 Oct;149(10):1118–22. NAIT and ASPEN Board of Directors. Nutrition in Clinical Practice 2010: 25, p. 548. 10 Interest in Malnutrition • Department of Justice Press Release Source: http://tinyurl.com/GSHmalnutrition 11 Department of Justice’s Claims Goo d Samarit an H ospit al • GSH employed a system that added malnutrition as a secondary diagnosis when the diagnosis was not warranted by manipulating the coding system • GSH employees used leading questions so that the physician would answer that the patient was malnourished , which was the result GSH wanted to achieve • Clinical forms that GSH used also injected false diagnoses of malnutrition into the record, which the coders then used to justify the code – By falsely coding inpatients with a secondary diagnosis of malnutrition, GSH caused its patient profile to appear worse than it was, thus increasing its reimbursement rate from the HSCRC. Federal health benefit insurance programs—Medicare, Medicaid, and the OPM’s Federal Health Benefits Program—all paid inpatient hospital bills at the rate set by the HSCRC and were all accordingly damaged by paying GSH at the inflated rate. Source: http://tinyurl.com/GSHmalnutrition 12 Department of Justice’s Claims Kernan HitlBltiHospital, Baltimore • Kernan’s CDSs reviewed every chart for evidence consistent with malnutrition – When suchidh evidence was fdfound—flfor example, whlbtttlthere a laboratory test result was consistent with malnutrition—the CDS would use a sticky note affixed to the chart to query the physician – The sticky note would indicate that the patient possibly had “Protein Malnutrition” and would prompt the physician to include the secondary diagnosis if he or she agreed with it – Treating physicians did frequently agree with the query, and “wrote the words ‘Protein Malnutrition’ in the chart in answer to the query and threw the sticky note away” • The coders would then code malnutrition for the patient by typing the words “protein malnutrition” into the computer system that included the ICD-9-CM information – This led the coders to a drop-down screen that listed kwashiorkor as the first choice at the top of the list • The government alleges that coders were “not to independently assess the quality of the evidence that led to the coding of ‘Kwashiorkor,’ ” and “were instructed to select it automatically instead of considering any of the other choices” Source: U.S. vs. Kernan Hospital – U.S. District Court, Maryland, July 30, 2012 Available at: http://tinyurl.com/cac8q4r 13 CMS Quarterly Compliance Newsletter Oct o ber 2012 , p. 6 Admitting diagnosis: Knee pain Summary of history and physical examination: • A 78-year-old female presented for an elective procedure on her right knee. On admission, it was noted that she had severe and painful degenerative damage of the right knee and she was admitted for total right knee replacement. • The patient had a history of hypertension, degenerative joint disease of multiple sites, and moderate protein malnutrition. Nutritional consult was obtained. Discharge summary: Patient had a total knee replacement on the right knee. Patient did well postoperatively and was started on physical therapy. Discharge to the rehab unit. Available at: http://tinyurl.com/CMSQCN201210 14 CMS Quarterly Compliance Newsletter OtbOctober 2012, p. 6 Finding and code correction: The provider coded the protein malnutrition as ICD-9-CM code 260, kwashiorkor, which is classified as a MCC. • According to Coding Clinic , Third Quarter 2009 (sic), protein malnutrition should be coded to category 263. – Therefore, 260 (kwashiorkor) was changed to 263.0 (()moderate malnutrition), which is classified as a non-CC. – This change in diagnosis code resulted in an MS-DRG change from 469 (major joint replacement or reattachment of lower extremity with MCC) to 470 (major joint replacement or reattach ment of l ower ext remit y with out MCC) . • These changes resulted in an overpayment. Available at: http://tinyurl.com/CMSQCN201210 15 Background EVOLVING MALNUTRITION DEFINITIONS 16 History of Malnutrition DfiitiDefinitions • As late as the 1920s, malnutrition was not considered to be a medical diagnosis Source: Boston Med Surg J 1920; 182:655–658. Available at: http://tinyurl.com/bsbvcw6 17 1979 Criteria for “Like lihoo d o f Ma lnut r ition” Major Intermediate Minor Vitamins Serum folate (ng/ml) < 3.0 < 6.0 > 6.0 Serum vitamin C (mg/dl) < 0.2 < 0.3 Anthropometrics (% of standard) Triceps skinfold < 20 < 60 Weight/height < 80 < 90 Arm muscle circumference < 60 < 80 Routine lab Lymphocyte ct (per mm3) < 1200 plus < 1200 < 1500 Serum albumin (g/dl) < 2.8 < 2.8 < 3.5 Hematocrit (%) < 37 (M); < 31 (F) < 43 (M); < 37 (F) Adapted from Weinsier RL, et al. Hospital malnutrition – A prospective evaluation of general medical patients during the course of hospitalization. American Journal of Clinical Nutrition. 32:418–426, 1979. Available at: http://tinyurl.com/c86urnp 18 Excerpt: Nestle® Min i Nut r itional A ssessment E Neuropsychological problems Assessment 0dtidi0=severe dementia or depression GLiG Lives ind epen den tly 1=mild dementia 0=no 1=yes 2=no psychological problems H Takes more than 3 prescriptions/day 0=yes 1=no F Body mass index (BMI) I Pressure sores or skin ulcers (weight in kg)/(height in m) 0=yes 1=no 0=BMI < 19 Etc..
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