Coding for Malnutrition- A Success Story

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Coding for Malnutrition-A Success Story
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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

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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 DRGs 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.

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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

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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

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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
• Blue Cross/Blue Shield
• Commercial
• Medicaid
• Medicaid MC
• Medicare
• Medicare Advantage
• Other Govt
• Self Pay

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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, gt18 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

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Chart review
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
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Sample Patient
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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/HRNs. 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.

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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

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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

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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

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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 hospitals overall morbidity and mortality
  rates-the more conditions identified in the
  patient the better the risk adjustment to the
  hospital

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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

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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

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Malnutrition related ICD-9 codes

• Type of Comorbidity associated with ICD-9

• ICD-9 codes related to nutrition

• MCC
• MCC
• MCC
• None
• None
• CC
• CC
• None
• CC

• 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

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ICD-9 Codes that potentially move DRGs

• Type of Comorbidity associated with ICD-9

• ICD-9 codes related to nutrition

• 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

• MCC
• MCC
• MCC
• None
• None
• CC
• CC
• None
• CC

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Next Steps

• Determine charting methods to correctly capture
  information pertinent to coders
• Helped physicians 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!

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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

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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

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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

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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

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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/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

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WVU Healthcare codes changes after improved
documentation
Code Description No. of times used No. of times used Status Pre Program Monthly Avg Avg During Program
260 Kwashiorkor 19 19 MCC 1.6 1.0
261 Nutritional Marasmus 73 73 MCC 6.1 3.2
262 Other Severe Protein-Calorie Malnutrition 102 102 MCC 8.5 52.3
263.0 Malnutrition Of Moderate Degree 74 74 None 6.2 29.7
263.1 Malnutrition Of Mild Degree 19 19 None 1.6 5.5
263.2 Arrested development following protein-calorie malnutrition 0 0 CC 0.0 0.0
263.8 Other Protein-Calorie Malnutrition 42 42 CC 3.5 1.8
263.9 Unspecified Protein-Calorie Malnutrition 741 741 CC 61.8 49.8
278.01 Morbid Obesity 602 602 None 50.2 84.3
783.22 Underweight 3 3 None 0.3 0.8
799.4 Cachexia 85 85 CC 7.1 18.0
V85.0 Body Mass Index less than 19, adult 0 0 CC 0.0 25.2
V85.4 Body Mass Index 40 and over, adult 395 395 CC 32.9 76.8

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

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

of cases with a CC or MCC of cases with a CC or MCC of cases with a CC or MCC 6.2 7.3
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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 hospitals bottom
  line.

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Physical Assessment
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What we learned...

• The dietitians felt they became better clinicians
  through improved education and changing their
  practice
• The physicians 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

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What we learned...

• Administration/Finance had a greater appreciation
  of dietitians 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

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References

• www.eatright.org
• www.all-things-medical-billing.com/medical-billing
  -codes.html
• www.cdc.gov
• www.ahrq.gov/qual/mortality/Hughessumm.pdf

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Contact information for consultants

• Michelle Hoppman, RD, LRD, CDEExecutive Success
  Coach
• DMA, Inc.871 Bowsprit RoadChula Vista, CA
  91914(716) 572-6502 Direct(619)
  656-2100 Main(619) 656-1321 Faxmichelle.hoppman.
  dma_at_gmail.com www.chefdon.com 

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Questions???