01-002 Kwashiorkor Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A kwashiorkor services billed on dates of service from January 1, 2017, through December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

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 conduct medical record/coding reviews on claims billed with the diagnosis of kwashiorkor, to determine if the diagnosis was correctly included on the claim. Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB Diagnosis Code

011X: Hospital Inpatient Part A

  • E40: Kwashiorkor, severe malnutrition with nutritional edema with dyspigmentation of skin and hair.
  • E42: Marasmic kwashiorkor, Intermediate form severe protein-calorie malnutrition.

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Medical notes to support the beneficiary’s medical condition for the billed service and to provide evidence documenting the attending physician’s diagnosis of kwashiorkor. This may include but not limited to:
    1. Admission notes
    2. History and Physical
    3. Progress notes
    4. Discharge summary
  2. Physician Orders to support evaluation, diagnosis and treatment for kwashiorkor.
  3. Full detailed itemization of services, including diagnosis codes
  4. Consultations, including dietary consultations, to support evaluation and treatment of kwashiorkor
  5. Dietary Notes to support evaluation, dietary treatment plan and beneficiary’s response to treatment for Kwashiorkor
  6. Lab/Diagnostic reports to support evaluation for kwashiorkor
  7. Medication Administration Record (MAR)
  8. Legible handwritten Physician and/or Clinician signatures
    1. Signature Attestation and Signature Log should be submitted when Physician or Clinician signatures are illegible
  9. Valid electronic physician and/or clinician signatures
  10. If an electronic health record is used, the Electronic Order Signature Process Form should be submitted to verify provider’s Electronic Ordering System is secure

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 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 Aug 22, 2019