01-002 Kwashiorkor Findings of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, conducted post-payment review of claims for Medicare Part A billed on dates of service from January 1, 2017 through December 31, 2017 with a diagnosis of kwashiorkor or marasmic kwashiorkor. Below are the review results:

Project ID Project Title Error Rate Claim Re-coded Rate
01-002 Kwashiorkor 4% 100%

Background

The Office of Inspector General (OIG), under Report A-13-14-00010 dated November 2017, titled “CMS Did Not Adequately Address Discrepancies in the Coding Classification for Kwashiorkor”, found that providers incorrectly billed the diagnosis code for kwashiorkor, for beneficiaries who did not have the disease. It was determined that providers should have used diagnosis codes for other forms of malnutrition, or no malnutrition diagnosis code at all.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and medical record/coding reviews on claims billed with the diagnosis of kwashiorkor or marasmik kwashiorkor, to determine if the diagnosis was correctly included on the claim. The selection of providers for this project was determined through data analysis.

Common Reasons for Denial

  • Incorrect Coding
    • The documentation submitted did not support the diagnosis billed on the claim. CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 indicates that review contractors “shall determine that an item/service is correctly coded.”
  • Incorrect Diagnosis-Related Group (DRG) Assignment
    • This claim was recoded to reflect the level of services supported by the documentation submitted. CMS IOM, Publication 100-08, Medicare Program integrity Manual, Chapter 6, Section 6.5.3 indicates that review contracts “delete any incorrect diagnoses and revise the DRG assignment as necessary.”

References/Resources

  • Social Security Act (SSA), Title XVIII, §§1812. Scope of Benefits
  • SSA, Title XVIII, §§1815(a). Payment to Providers of Services
  • SSA, Title XVIII, §§1833(e). Payment of Benefits
  • SSA, Title XVIII, §§1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §§1886. Payment to Hospitals for Inpatient Hospital Services
  • SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • 42 Code of Federal Regulations (C.F.R) §412.1(a)(1). Scope of Part
  • 42 C.F.R §412.2. Basis of payment
  • 42 C.F.R. §424.5(a)(6). Basic conditions
  • 42 C.F.R. §482.24(c)(1). Condition of Participation: Medical Record Services
  • CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section3.2.2. Consistency Edits for Institutional Claims
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 10.2. Inpatient Claim Diagnosis Reporting
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.1. Coverage Determinations
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4. Coding Determinations
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5.3. DRG Validation Review

Last Updated Jan 27, 2020