Findings of Severe Malnutrition and Cardiovascular NM Reviews

on Wednesday, 16 May 2018. All News Items | MAC Reviews

Other than in football, my home state of Alabama does not rank 1st in many areas. One area where we are tied for first is not a desired distinction – Alabama ties with Oklahoma for the most number of F5 and EF5 (the most severe rating) tornadoes and is consistently in the top ten for all types of tornadoes. I clearly remember December 16, 2000. Although it was December, the temperature was in the high 70’s, the sky was clear and the sun was shining brightly. Stores were packed as people took advantage of the beautiful weather for Christmas shopping. But it was a mistaken quiet as the weather forecasters warned of a PDS (particularly dangerous situation) – a term you come to fear if you live in a tornado-frequented area. Later that afternoon, a destructive F4 tornado hit communities south and east of Tuscaloosa, Alabama (my hometown) resulting in 11 deaths, over 125 injuries, and approximately $12 million dollars in damage.

There may be a mistaken quiet currently concerning the medical review activity of the Medicare Administrative Contractors (MACs).  The medical review updates on the MAC websites are scarce. As you can see from the table at the end of this article, only one new Targeted Probe and Educate (TPE) review was posted for last month and only three results. At least for some MAC Jurisdictions, this is a mistaken perception as providers in these jurisdictions are regularly receiving Additional Documentation Requests (ADRs) for medical records for a TPE review. I suppose this lull in reported activity is to be expected as the MACs transition from the prior review format to the new TPE strategy. Also, the MACs are likely providing one-on-one education with individual providers before they publish findings and guidance on their websites.

All providers should try to learn from any medical review findings that are published by the MACs. The findings from the two topics addressed in the three TPE results from this month are:

Cardiovascular Nuclear Medicine Studies – Although the Round 2 denial rates were low at around 20%, the reasons for denials are errors that are easily avoidable with a little effort.

  • Documentation is missing a history & physical (H&P) and/or progress notes to support diagnosis or need for testing.
  • Documentation is missing a signed physician’s order for testing.
  • Documentation is missing a formal report or included an incomplete report which did not include stress/EKG portion or was not signed by the physician.

Severe Malnutrition (ICD-10 Codes E41 and E43) – Both Jurisdictions H and L had high error rates for Round 1 of this TPE – 80-100% partial or complete denials. The most common reason for the denials was: “Partial denials for diagnosis code adjustment based on insufficient documentation to support the billing of diagnosis code 43- Severe protein calorie malnutrition.”

As we know, Severe Malnutrition, E43, can only be reported when documented by the physician.

MMP recommends querying the physician when the coder finds the clinical picture of Severe Malnutrition described in the record without the diagnosis.

Here are some conditions that indicate Severe Malnutrition:

    • Significant muscle wasting, loss of subcutaneous fat.
    • Nutritional intake of <50% of the recommended intake for 2 weeks or more (per dietitian).
    • Bedridden or significantly reduced functional capacity.
    • Weight loss of >2% in 1 week, 5% in 1 month, or 7.5% in 3 months.

Also, query the physician when a history of any type of Malnutrition is listed in the Past Medical History of the H&P to see if the condition is still present.

Resources: Coding for Malnutrition in the Adult Patient:  What the Physician Needs to Know, Wendy Phillips, MS, RD, CNSC, CLE, Director Nutrition Systems, University of Virginia Health System, Charlottesville, VA 

If your hospital hasn’t been receiving ADRs for TPE reviews, do not become complacent – they will be coming. In the meantime, watch your MAC’s websites for announcements of their TPE target areas, check Medicare manual and coverage policy guidelines for any target areas, and make sure your coding, billing, and documentation follow the guidance. During the quiet is a good time to prepare.

MR Updates for May 2018
MACService DescriptionService CodeDateError/Denial RateStatus
Palmetto JM Heart Failure & Shock w MCC and Heart Failure & Shock w CC DRGs 291, 292  4/27/2018   New
Novitas JH Severe Malnutrition ICD-10 E41 and E43 4/30/2018 90-100% Round 2
(July 2018)
Novitas JL Severe Malnutrition ICD-10 E41 and E43 4/30/2018 90-100% Round 2
(July 2018)
Novitas JL Cardiovasc NM CPT 78451-78454, 78466-78483, 78494, 78496, 93015-93018   ~20% Round 3
(May 2018)


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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