01-045 Malnutrition Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for CMS, is conducting post-payment review of claims for Medicare Part A billed on dates of service from January 1, 2019 through December 31, 2019. 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-03-17-00010 dated July 2020, titled “Hospitals Overbilled Medicare $1 Billion By Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims”, found that hospitals incorrectly billed claims with the diagnosis codes for severe malnutrition. Through medical record review, the OIG determined that providers should have used diagnosis codes for other forms of malnutrition, or no malnutrition diagnosis code at all. This resulted in a higher Medicare Severity Diagnosis Related Group (MS-DRG) reimbursed to the hospitals and an estimated $1 billion in overpayments.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct claim/coding reviews on inpatient claims billed with a severe malnutrition diagnosis, to determine if the diagnosis was correctly included on the claim. Noridian will complete claim reviews on supporting documentation to validate that an appropriate diagnosis and MS-DRG assignment were included on the claim in accordance with applicable statutory, regulatory, sub-regulatory, and coding guidance.

Claim Sample Detail

POS / Revenue Code / TOB CPT / HCPCS / ICD-9 / ICD-10
11x: Hospital Inpatient Part A
  • E41: Nutritional marasmus (severe malnutrition with marasmus
    Severe undernourishment causing an infant’s or child’s weight to be significantly low for their age (e.g., below 60 percent of normal)
  • E43: Unspecified 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 collection and submitting pertinent information to decrease provider burden.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. History and physical reports (include medical history and current list of medications)
  2. Nutritional evaluation, consultation, and progress notes
  3. Practitioner, nurse, and ancillary progress notes
  4. Nursing documentation (i.e., Nursing notes and admission assessment – Lines; Medication & IV administration records; nursing treatment sheets such as: Skin care/wound care treatment sheets. Respiratory treatments and oxygen therapy records)
  5. Initial hospital inpatient care as applicable
  6. Discharge summary from the hospital, Skilled Nursing, Continuous Care, and/or Respite Care facilities
  7. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  8. Pre-Hospital documentation
  9. Vital sign records, weight sheets, care plans, treatment record
  10. Review of beneficiary prior and current medical and functional conditions and comorbidities
  11. Itemized breakdown of charges and subtotals per specific revenue code range(s) including the total charges of all revenue codes billed
  12. Documentation to support the DRG billed
  13. Documentation supporting the diagnosis code(s) required for the item(s) billed
  14. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  15. Advance Beneficiary Notice of Liability (ABN); if applicable
  16. Any other supporting documentation
  17. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  18. PLEASE NOTE: It is the responsibility of the supplier/provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1812. Scope of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Providers must furnish information
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1886. Payment to Hospitals for Inpatient Hospital Services
  • Social Security Act (SSA) Title XVIII, Section 1879. Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Code of Federal Regulations (CFR) Title 42, Section 411.15(k)(1). Particular services excluded from coverage
  • Code of Federal Regulations (CRF) Title 42, Section 412.1(a)(1). Scope of Part
  • Code of Federal Regulations (CFR) Title 42, Section 412.2. Basis of payment
  • Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6). Basic conditions
  • Code of Federal Regulations (CFR) Title 42, Section 482.24(c)(1). Condition of participation: Medical record services
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 80.3.2.2. Consistency Edits for Institutional Claims
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 23, Section 10.2. Inpatient Claim Diagnosis Reporting
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section.3.2.3.2. Time Frames for Submission
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.8 B. Post payment Review Time Frames
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6.2.1. Coverage Determinations
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6.2.4. Coding Determinations
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 6, Section 6.5.3. DRG Validation Review
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 6, Section 6.5.4. Review of Procedures Affecting the DRG

Last Updated Feb 16, 2022