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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.

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 assitistant tdi direc tor of fthf the food and nut titirition 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.

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

Malnutrition Prevalence “UdUnderdi agnosi 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

Department of Justice’s Claims Good S amarit 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 ob er 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

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

1979 Criteria for “Like lihoo d of M al nut riti on”

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® Mini N ut riti onal A ssessment

E Neuropsychological problems Assessment 0dtidi0=severe dementia or depression GLiG Lives i nd epend entl y 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... 1=BMI 19 < 21 2=BMI 21 < 23 Assessment (max. 16 points) 3=BMI 23 or greater Screening score Total assessment (max. 30 points) Screening score Malnutrition indicator score (subtotal max. 14 points) 17–23.5 points=at risk of malnutrition 12 points or higher=Normal—not at 17 points or less=malnourished risk—no need to complete assessment 11 points or below=possible malnutrition—continue assessment

Source: http://tinyurl.com/NestleMNA

Subjective Global Analysis

SGA SGA SGA rating rating rating Medical history A B C Weight change Clothing size: No change/% change Overall loss: In past month/in past 6 months/in past year % loss of usual weight: < 5%, 5%–10%, > 10% Change in previous 2 weeks: Increase (gain)/no change (stabilization)/decrease (continued loss) Dietary intake Reduction/unintentional/intentional Overall change: No change/change/Increase or decrease Duration: Weeks/months Diet change: Suboptimal solids/full liquid diet/hypocaloric fluids/NPO (starvation) Gastrointestinal symptoms (persisting for > 2 weeks) None/diarrhea/dysphagia or odynaphagia/nausea/vomiting/anorexia Functional impairment None/mild/severe Duration: Days/weeks/months Type: Ambulatory/bedridden Source: Sungurtekin et al. Nutr Clin Prac 2008; 23:635–641

20 Common Use of Albumin in MlMalnut titirition C Citiriteria

• Throughout the 1990s and 2000s, current weight and albumin levels continued to factor in malnutrition criteria – Merck Manual uses similar criteria today

Mild Moderate Severe Measurement Normal Undernutrition Undernutrition Undernutrition Normal weight (%) 90–110 85–90 75–85 < 75 Body mass index 19–24* 18–18.9 16–17.9 < 16 (()BMI) Serum albumin (g/dL) 3.5–5.0 3.1–3.4 2.4–3.0 < 2.4 Serum transferrin 220–400 201–219 150–200 < 150 (mg/dL) Total l ymphoc y te 2000–3500 1501–1999 800–1500 < 800 count (per µL) Delayed 22 1 0 hypersensitivity index†

Seidner DL. Nutritional issues in the surgical patient. Cleveland Clinic Journal of Medicine 2006:73(1) pp. S77–S81. Merck Manual – available at: www.tinyurl.com/MerckMalnutrition 21

2004—Concern for Blood Bi omark ers

• Inflammation factors in the definition and etiology of malnutrition – Interleukins, tumor necrosis factor, and other factors are released with inflammation • Acute phase reactant proteins: – Class of proteins that rise or fall with advent of chronic/ acute inflammatory processes, such as infections, trauma, surgery, cancer, autitoimmune processes, burn ijinjur ies, Crohn’s disease • Positive – C-reactive protein, plasminogen, ferritin, haptoglobin, fibrinogggen, among others • Negative – Albumin, prealbumin, transferrin, antithrombin – Upon correction of the inflammatory state, these will return to normal

“Serum proteins as markers of nutrition: What are we treating?” Banh, L. Practical Gastroenterology. October 2004. 22 2008—“Normal” Albumin Levels i“MdtMltiti”in “Moderate Malnutrition”

Note that the serum albumin is often over 3.5 in “moderately malnourished” patients

Subjective Global Well Moderately Severely Analysis designation nourished malnourished malnourished Weight, kg 76. 36 ± 19. 90 63. 15 ± 7527.52 53. 50 ± 6736.73 BMI, kg/m2 27.5 ± 8.2 23.5 ± 2.5 19.8 ± 2.7 MAC, cm 30.5 ± 3.8 26.7 ± 2.8 24.3 ± 2.8 TSF, mm 29.2 ± 5.0 25.1 ± 3.6 22.7 ± 3.7 MAMC 21.3 ± 2.6 18.8 ± 2.1 17.2 ± 1.9 APACHE II 21.62 ± 14.88 27.85 ± 12.49 37.07 ± 13.28 SAPS II 33.45 ± 19.37 42.64 ± 21.30 61.86 ± 19.61 Albumin, g/dL 3.5 ± 0.8 3.4 ± 0.9 2.3 ± 0.9 Total protein, g/dL 5.7 ± 1.1 5.7 ± 1.1 4.5 ± 1.2 C-reactive protein 6.9 ± 6.4 7.8 ± 7.0 11.8 ± 5.6 Mortality, % 14 27 64 APACHE II, Acute Physiology and Chronic Health Evaluation; BMI, body mass index; MAC, mid-arm circumference; MAMC, mid-arm muscle circumference; SAPS, Simplified Acute Physiologic Score; TSF, triceps skinfold thickness

Source: Sungurtekin H et al. Nutritional assessment in the critically ill. Nutrition in Clinical Practice 2008:23(6), pp. 635–641. 23

May 2012 GChGame Changer

Source: www.tinyurl.com/2012ASPENmalnutrition

24 Factors in DtDeterm iiining MlMalnut titirition

• Insufficient energy intake • Weight loss • Loss of muscle mass • Loss of subcutaneous fat • Localized or generalized fluid accumulation that may sometimes mask weight loss • Diminished functional status as measured by handgrip strength 2 out of 6 criteria used

Prealbumin and albumin are no longer criteria for malnutrition

Stratification of Malnutrition

Non-severe Inflammatory state Severe (dt)(moderate) None 2 or more out of 6 2 or more out of 6 (e.g., anorexia nervosa, specific to this category specific to this category starvation) Mild to moderate (e.g., chronic illness or 2 or more out of 6 2 or more out of 6 organ failure, sarcopenic specific to this category specific to this category obesity, cancer) Marked (e.g., major infections, 2 or more out of 6 2 or more out of 6 burns, trauma, closed specific to this category specific to this category head injury)

Note that AND and ASPEN did not differentiate between mild and moderate malnutrition

26 Polling Question

• Which one of the following clinical indicators does NOT support a diagnosis of malnutrition? A. IffiitInsufficient energy i itkntake B. Weight loss C. Loss of muscle mass D. Loss of subcutaneous fat E. Low serum albumin or prealbumin F. Diminished functional status as measured by handgrip strength

What About MdKhik?Marasmus and Kwashiorkor?

• Marasmus: A state in which virtually all Very rare in the available body fat stores have been United States exhausted due to starvation – Conditions that produce marasmus in developed countries tend to be chronic and indolent, such as cancer, chronic pulmonary disease, and anorexia nervosa – Patients appear starved or “cachetic” • Kwashiorkor: An acute form of protein- Probably energy malnutrition characterized by edema, should not be irritability, anorexia, ulcerating dermatoses, coded unless and an enlarged liver with fatty infiltrates deemed to be – Occurs mainly in connection with acute, life- valid by the threatening illnesses such as trauma and provider sepsis, and chronic illnesses that involve acute-phase inflammatory responses – Now called “severe acute malnutrition”

Source: www.who.int/nutrition/topics/malnutrition/en/index.html

28 What About Cachexia?

• Sarcopenia • Cachexia and malnutrition – Loss of muscle mass and differences muscle strength1 – Cachexia is to be considered • Cachexia the result of the complex interplay between underlying – A multifactorial syndrome disease, disease-related characterized by severe metabolic alterations, and, body weight, fat, and in some cases, the reduced muscle loss, and increased availability of nutrients protein catabolism due to – Malnutrition is a state of underlying disease(s)1 nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size, and composition), function, and clinical outcome 1 Muscaritoli M, Anker SD, Argiles J, et al. Consensus definition of sarcopenia, cachexia, and pre-cachexia. Clinical Nutrition 2010:29(2), pp. 154–159. Available at: www.ncbi.nlm.nih.gov/pubmed/20060626 29

Other Nutritional Terms

• Athrepsia – A form of protein-energy malnutrition primarily due to prolonged severe caloric deficit, usually during the first year of life, with growth retardation and progressive wasting of subcutaneous fat and muscle, but usually with retention of appetite and mental alertness – Called also infantile atrophy and pedatrophia • Emaciation – Excessive leanness; a wasted condition of the body

30 Background ICD-9-CM AND ICD-10-CM NOSOLOGIES

ICD-9-CM and ICD-10-CM CdiCoding C onventi ons

• ICD-9-CM Volume 1 and 2 – First look up a term in the Index to Diseases (Volume 1) – Then cross-reference the term in the Table to Diseases (Volume 2) • Follow all the “excludes,”“ code first,” and other instructions • Additional instructions – ICD-9-CM Official Guidelines for Coding and Reporting – Co ding Clin ic for ICD-9-CM for additi onal instructions 32 Section: Nutritional Deficiencies (260–269)

Excludes deficiency anemias (280.0–281.9) • Category list – 260: Kwashiorkor – 261: Nu tr itiona l marasmus – 262: Other severe protein-calorie malnutrition – 263: Other and unspecified protein-calorie malnutrition – 264: Vitamin A deficiency – 265: Thiamine and niacin deficiency states – 266: Deficiency of B-complex components – 267: Ascorbic acid deficiency – 268: Vitam in D de fic iency – 269: Other nutritional deficiencies 33

ICD-9-CM Table of Diseases

• 260 Kwashiorkor • 263 Other and unspecified – Nutritional edema with protein-calorie malnutrition dyspigmentation of skin – 263.0 Malnutrition of and hair moderate degree • 261 Nutritional marasmus – 263.1 Malnutrition of – Nutritional atrophy mild degree – Severe calorie deficiency – 263.2 Arrested development following protein-calorie – Severe malnutrition NOS malnutrition • 262 Oth er severe protitein- Nutritional dwarfism calorie malnutrition Physical retardation due – Nutritional edema without to malnutrition mention of dyspigmentation – 263.8 Other protein-calorie ofkif skin and dhi hair malnutrition – 263.9 Unspecified protein- calorie malnutrition Dystrophy due to malnutrition Malnutrition (calorie) NOS Excludes: nutritional deficiency NOS (269.9) 34 Index to Diseases

• Anasarca • Deficiency – Nutr it iona l 262 – Ca lor ie, severe 261 • Athrepsia 261 – Edema 262 – A form of protein-energy – Multiple, syndrome 260 malnutrition primarily due to – Nutrition, nutritional 269.9 prolonged severe caloric deficit, • specified NEC 269. 8 usually during the first year of life, – Protein 260 with growth retardation and progressive wasting of • Deprivation subcutaneous fat and muscle, but – Protein (familial) usually with retention of the (kwashiorkor) 260 appetite and mental alertness – Food 994.2 – Called also infantile atrophy and • Development pedatrophia – Due to malnutrition • Atroppyhy (protein-calorie) 263.2 – Infantile 261 • Diabetes – Nutritional 261 – Lancereaux’s (diabetes • Cachexia mellitus with marked emaciation) – Due to malnutrition 799.4 250.8 [261] – Malignant 799.4

Index to Diseases

• Dwarf • Food – Nutr it iona l 263. 2 – Dii9942Deprivation 994.2 • Dystrophy • Famine 994.2 – Due to malnutrition 263.9 – Edema 262 – Nutritional 263.9 • Hunger 994.2 • Effect • Hydrops – Hunger 994.2 – Nutritional 262 • Edema • Hypoproteinosis 260 – Inanition 262 – Protein-calorie NEC 262 – Nutritional (newborn) 262 • Inanition 263.9 • with dyspigmentation, skin and – With edema 262 hair 260 – Due to – Starvation 262 • deprivation of food 994.2 • Emaciation (du e to • malnutrition 263.9 malnutrition) 261 • Kwashiorkor (marasmus type) 260

36 Index to Diseases

• Malnutrition 263.9 • Malnutrition (continued) – CliiComplicating pregnancy 648. 9 – LkLack of care, or neglect (c hild) – Degree (infant) 995.52 • first 263.1 • adult 995.84 • second 263.0 – Malignant 260 • third 262 – Mild (protein) 263 . 1 • mild (protein) 263.1 – Moderate (protein) 263.0 • moderate (protein) 263.0 – Protein 260 • severe 261 – Protein-calorie 263.9 • protein-calorie 262 • mild 263.1 – Fetus 764.2 • moderate 263.0 • “light-for-dates” 764.1 • severe 262 – Following gastrointestinal • specified type NEC 263.8 surgery 579.3 – Severe 261 – Intrauterine or fetal 764.2 • fetus or infant “light-for-dates” 764.1

Index to Diseases

• Marasmus 261 • Pedatrophia 261 – BiBrain 331. 9 • Pluricarential syndrome of – Due to malnutrition 261 infancy 260 – Intestinal 569.89 • Plurideficiency syndrome of – Nutritional 261 infancy 260 – SilSenile 797 • Polycarential syndrome of – Tuberculous NEC (see also infancy 260 tuberculosis) 011.9 • Pregnancy • Nutrition, deficient or insufficient (particular kind of food) 269. 9 – Malnutrition (conditions classifiable to 260–269) 648.9 – Due to – Nutritional deficiency (conditions • insufficient food 994.2 classifiable to 260–269) 648.9 – Lack of • care (()()child) (infant) 995.52 • adult 995.84 • food 994.2

38 Index to Diseases

• Prekwashiorkor 260 • Starvation (inanition) (due to lack • Protein of f ood) 994 . 2 – Deficiency 260 – Edema 262 – Malnutrition 260 – Voluntary NEC 307.1 • Retardation • Syndrome – Growth – MlilMultiple • due to malnutrition 263.2 • deficiency 260 – Physical • Wasting • due to malnutrition 263.2 – Disease 799.4 • SiSarcopenia – no code – Due to mal nu triti on 261 – Extreme (due to malnutrition) 261

ICD-9-CM Official Guidelines UtiDiUncertain Diagnoses

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms indicating uncertainty, code the condition as if it existed or was established • CtCaveats – Does not include admitting or interim notes (CC, 3Q 2005, p. 22) • Thus must be discharge summary, note, or order – The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis • Must be clinically supported or reasonably valid • Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals

40 ICD-9-CM Official Guidelines Documentation for BMI and Pressure Ulcer Stages

• For the BMI and pressure ulcer stage codes, code assignment may be bdbased on me dildical recor ddd documen ttiftation from c liiihlinicians who are no ttht the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care ofthf the pati ent t( (e.g., a di dititietitian o ften d ocument s th e BMI and nurses often document the pressure ulcer stages) – However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider – If th ere i s confli cti ng medi ca l recor d documen ta tion, e ither from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification • The BMI and pressure ulcer stage codes should only be reported as secondary diagnoses – As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses)

ICD-9-CM Official Guidelines

• Cachexia (()799.1) is in Chap ter 16 6. Signs and symptoms Codes that describe symptoms and signs, as opposed to diagg,noses, are acce ptable for re pgppporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill- Defined Conditions (codes 780.0–799.9), contains many but not all codes for symptoms 7. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification

42 Coding Clinic Advice ChiCachexia

• 3rd Quarter 2006, • ICD-9-CM Index pp. 14–15 – Cachexia – Patient described as • Cancerous (see also cachectic in the setting Neoplasm, by site, of advanced lung malignant) 799.4 cancer and losing 20 • Due to malnutrition pounds over 2 months 799.4 – CC sttdthttated that • Malignant (see also Neoplasm, by site, “malignant cachexia” malignant) 799.4 or “cachexia due to malnutrition” could not be coded and that It appears that if cachexia malnutrition could not and malnutrition coexist be coded since it was and are documented, both not documented can be coded

Coding Clinic Advice MdModerat e-Severe M al nut riti on • CC, 3rd Quarter 2012, p. 10 – Physician documents moderate-severe malnutrition – CC requires a query to determine which of these apply • If the answer is “severe,” assign code 261, nutritional marasmus • If the answer is “moderate,” assign code 263.0, malnutrition of moderate degree

44 “Moderate” Protein Malnutrition

• Malnutrition CC, 3rd Q 2009, p. 6 – Mild (protein) 263.1 Physician documented – Moderate (protein) “moderate protein 263.0 malnutrition.” Advised – Protein 260 to code 263.0, moderate – Protein-calorie 263.9 malnutrition. • mild 263. 1 • moderate 263.0 Did not address need • severe 262 to query if the physician • specified type onldly document t“s “pro titein NEC 263.8 malnutrition” without the – Severe 261 word “moderate.”

Polling Question

• Which of the following conditions can (or should) be coded without the need for a query if documented on an iihidhilinpatient history and physical or progress note? A. Suspected protein calorie malnutrition B. Moderate-severe malnutrition C. Protein malnutrition D. Kwashiorkor E. None of the above

46 Current DRG Methodologies

• Medicare-Severity • MS-DRG Diagnosis Related Groups – Major – Used for traditional comorbidity/complication Medicare inpatient (MCC) admissions – Comorbidity/ • All-Payer-Refined Diagnosis complication (CC) Related Group – No MCC/CC – Severity of illness (SOI)— • APR-DRG inpatient reimbursement – 4: Extreme – Risk of mortality (ROM)— – 3: Severe AHRQ Inpatient Quality – 2: Moderate Indicator (and others) – 1: Mild expected mortality • Hierarchical Conditions • HCCs Classifications – Relative weight based upon documented – MdiMedicare Advan tage diagnoses submitted – ACOs in a calendar year

DRG and HCC Considerations SdDiSecondary Diagnoses

ICD-9-CM APR-DRG APR-DRG HCC Comm Inst SHORT DESCRIPTION MS-DRG v30 HCC Title Code SOI ROM Hier HCC RW HCC RW 260 KhikKwashiorkor MS-DRG MCC 4 2 21 PtiProtein-ClCalori e MMlalnu tititrition 0. 856 0. 374 261 Nutritional marasmus MS-DRG MCC 4 2 21 Protein-Calorie Malnutrition 0.856 0.374 262 Oth severe malnutrition MS-DRG MCC 4 2 21 Protein-Calorie Malnutrition 0.856 0.374 Malnutrition mod 263.0 MS-DRG CC 3 1 21 Protein-Calorie Malnutrition 0.856 0.374 degree 263. 1 Malnutrition mild degree MS-DRG CC 2 1 21 Protein-Calorie Malnutrition 0. 856 0. 374 263.2 Arrest devel d/t malnutr MS-DRG CC 3 1 21 Protein-Calorie Malnutrition 0.856 0.374 Protein-cal malnutr 263.8 MS-DRG CC 3 1 21 Protein-Calorie Malnutrition 0.856 0.374 NEC Protein-cal malnutr 263.9 MS-DRG CC 3 1 21 Protein-Calorie Malnutrition 0.856 0.374 NOS Nutrition deficiency 269.9 21 NOS 799.4 Cachexia MS-DRG CC 2 3 21 Protein-Calorie Malnutrition 0.856 0.374 995.52 Child neglect-nutrition MS-DRG CC 3 2 995.84 Adult neglect-nutrition MS-DRG CC 2 1 V85. 0 BMI less than 19, adult MS-DRG CC 1 1 V85.41 BMI 40.0-44.9, adult MS-DRG CC 2 1 V85.42 BMI 45.0-49.9, adult MS-DRG CC 2 1 V85.43 BMI 50.0-59.9, adult MS-DRG CC 2 1 V85.44 BMI 60.0-69.9, adult MS-DRG CC 2 1 V85.45 BMI 70 and over, adult MS-DRG CC 2 1

Malnutrition (and its specificity) has an impact on risk-adjustment methodologies Note: Data applicable to fiscal year 2013 48 Pre-Implementation

• CDI created physician queries referencing RD documentation of malnutrition and any treatment/resources utilized. Physicians were requidtdired to documen t any per tittinent diagnoses or conditions. Billing was delayed. • Physicians did not regularly review the RD’s computerized documentation in the hybrid record. • Physicians shared desire for additional malnutrition education.

Building a DRG MlMalnut titirition P rogram • Evaluate what is currently being done • Contact the medical coding team responsible for coding ICD-9 codes • Introduce malnutrition coding to registered dietitians • Develop malnutrition diagnostic form for facility

50 Severe protein- Unspecified Malnutrition of Malnutrition of Diagnosis: calorie protein-calorie Cachexia modtdderate degree mild d egree malnutrition malnutrition

Criteria: Two or more criteria must be present

Weight status < 80% < 90% > 90% from IBW

> 5% in 1 mo. > 5% in 1 mo. > 5% in 1 mo. > 5% in 1 mo. 1 May not see Weight loss > 7.5% in 3 mo. > 7.5% in 3 mo. > 7.5% in 3 mo. > 7.5% in 3 mo. change in from UBW > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. weight status > 20% in 12 mo. > 20% in 12 mo. > 20% in 12 mo. > 20% in 12 mo. BMI <18.5

Time course to 2 Days to weeks Not specified Days to weeks Days Not specified development

Depletion of fat Moderate to tissue and skeletal severe fat tissue Mild muscle muscle mass. and muscle Mild muscle Physical wasting may or Muscle wasting Consideration: 3 atrophy, including wasting, poor appearance may not be not apparent Other disease temporal and bony wound healing apparent processes can prominences, poor contribute greatly wound healing to this diagnosis. Inadequate intake Inadequate intake 4 Intake for > 7 days for > 7 days

52 Schedule time to present at physician meeting • Introduce role of RD in malnutrition coding • Present malnutrition coding form for approval • Ensure justification for all criteria presented in form (i.e ., references )

Obtain approval of form through medical records

Begin education to physicians, nursing, unit secretaries, medical coding • Articles in physician newsletters and nursing emails • Post signage in the physicians’ lounge and break rooms • Attend nursing and unit meetings

Implementation

• RDs initiated placing the form on the chart when appropriate • Clinical nutrition manager worked with information services to create a report identifying patients that the RD had documented with an ICD-9 code • Report designed to auto-print to the CDI printer and alert CDI staff • CDI and medical record staff responsible for ensuring physician completion • Mindy and Joann worked with information services to create a report that allows CDI to run reports from coded data to track use of the form, including improved documentation and financial impact when a malnutrition code is the only MCC or CC 54 Building a DRG MlMalnut titirition P rogram

Implement ppgrogram

Develop tracking system

Educate all disciplines on form Obtain physician approval of form

Introduce coding to RDs and develop form

Evaluate what is currently being done and contact team responsible for coding

Case Study

• 64-year-old male • 6 ft, 180 pounds (101% IBW) • Admitted with multiple myeloma • Patient reported poor PO intake for “th”itdit“months” prior to admit

56 Severe protein- Unspecified Malnutrition of Malnutrition of Diagnosis: calorie protein-calorie Cachexia modtdderate degree mild d egree malnutrition malnutrition

Criteria: Two or more criteria must be present

Weight status < 80% < 90% > 90% from IBW

> 5% in 1 mo. > 5% in 1 mo. > 5% in 1 mo. > 5% in 1 mo. 2 May not see Weight loss > 7.5% in 3 mo. > 7.5% in 3 mo. > 7.5% in 3 mo. > 7.5% in 3 mo. change in from UBW > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. > 10%in6mo% in 6 mo. weight status > 20% in 12 mo. > 20% in 12 mo. > 20% in 12 mo. > 20% in 12 mo. BMI <18.5

Time course to 3 Days to weeks Not specified Days to weeks Days Not specified development

Depletion of fat Moderate to tissue and skeletal severe fat tissue Mild muscle muscle mass. and muscle Mild muscle Physical wasting may or Muscle wasting Consideration: 4 atrophy, including wasting, poor appearance may not be not apparent Other disease temporal and bony wound healing apparent processes can prominences, poor contribute greatly wound healing to this diagnosis. Inadequate intake Inadequate intake 5 Intake for > 7 days for > 7 days

The Impact of Coding on RiReim bursement

• DRG 842: Lyypmphoma and non-acute $9,199 leukemia w/o CC/MCC RW 1.0389, LOS = 3.2 • DRG 841: Lymphoma and non-acute $14, 501 leukemia with CC RW 1.6376, LOS = 5.1 • DRG 840: Lymphoma and non-acute $25,960 leukemia with MCC RW 2.9317, LOS = 7.8

Difference with the documentation $16,761 of severe malnutrition

58 Engaging and Impacting Care

• RDs now lookinggp for patients with malnutrition and implementing more aggressive interventions. • Nursing alerted to importance of nutritional interventions and help with encouragement of meals and supplements. • Physicians are diagnosing malnutrition early on. They are more aware of the criteria due to the discussion with RDs and exposure to the form.

2009 2010 2011 2012 873 1247 1321 1054

DRG Malnutrition POtProgram Outcomes

DRG reimbursement SJMC SMMC July $64,712 $17,494 August $13,820 $2,646 September $6, 947 $4, 286 October $31,336 $6,391 November $14,568 $9,378 December $0 $3,562 January $30,528 $3,770 February $53,798 $0 March $5,140 $2,192 April $26,027 $0 May $5,859 $9,477 June $47,494 $0 Total $300, 229 $59, 196 Grand total $359,425

60 DRG Malnutrition POtProgram Outcomes • Early identification and treatment of malnourished patients • Relationshipppys built with physicians and medical coding team • Improved collaboration between healthcare disciplines • Recognition from executive leadership

Lessons Learned

• Be sure malnutrition assessment doesn’t include the term “query.” • Identify who is responsible for obtaining the physician’s signature. • Refer physician questions regarding malnutrition diagnoses to the RD. • Determine how long you (who is you?) will hold the chart before billing if the physician doesn’t sign the form. • Stay up-to-date on research. RDs should update the fhidlihform as necessary when guidelines change. • Stress it’s a win-win for the patient and all involved. It doesn’t mean one department is getting credit over another.

62 Good Documentation Tool fSfor Survi ilval

• Ensure accuracy: Perform coding and CDI quality audits with special focus on use of code 260. • RD: Identify malnutrition or similar nutritional concerns early; provide physician education related to malnutrition as needed. • CDI staff: Work with physicians to document any condition that coexists at the time of admission, develops subtldithtdffttttidbsequently during the stay, and affects treatment received and/or length of stay. Good documentation demonstrates an accurate reflection of length of stay, severity of illness, risk of mortality, and medical necessity , reducing denials and outside audits. • Coders & CDI: Look for supporting clinical evidence for all conditions documented by the provider before coding. Develop internal policies for referring cases with questions.

Building an Effective Re lati onshi p

As a group, discuss: Collaborate • DRG codes with RDs • Coding rules • Roles and responsibilities

Define processes Respect skill sets needed of each discipline

Continue with Educate ongggoing follow- up physicians and discussion

Identify team Define how DRG codes members are established for patient conditions

64 Questions & Answers

James S. Kennedy, Joann A. Agin, Mindy Hamilton, MD, CCS RHIT RD, LD Managing Director, Regional Manager, Registered FTI Healthcare Group Data Quality Dietitian Brentwood, Tenn., Carondelet Health Kansas City, Mo. and Atlanta Kansas City, Mo.

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67 Certificate of Attendance

attended “Malnutrition Coding and Documentation: Strategies to Implement a Compliant Query Process”

a 90-minute audio conference on March 14, 2013

Hank Boye Executive Vice President, Information Solutions and Media HCPro, Inc.