Knowledge Base Article

Coding Kwashiorkor has been and continues to be a hot topic for contractors (e.g., Recovery Auditors and the Office of Inspector General (OIG)). In fact, auditing claims including a diagnosis of Kwashiorkor to determine if the record adequately supports the diagnosis was a new scope of work in the FY 2014 OIG Work Plan and is a continued scope of work in the FY 2015 OIG Work Plan. In the Work Plan the OIG indicates that “a diagnosis of Kwashiorkor on a claim substantially increases the hospitals’ reimbursement from Medicare.”

What is Kwashiorkor?

According to the National Institutes of Health, “Kwashiorkor is a form of malnutrition that occurs when there is not enough protein in the diet. Kwashiorkor is most common in areas where there is:

• Famine
• Limited food supply
• Low levels of education (when people do not understand how to eat a proper diet)
• Dates of service of records reviewed ranged from 2010 – 2013 with most records being prior to 2013.

This disease is more common in very poor countries. It often occurs during a drought or other natural disaster, or during political unrest.”

“Kwashiorkor is very rare in children in the United States. There are only isolated cases. However, one government estimate suggests that as many as 50% of elderly people in nursing homes in the United States do not get enough protein in their diet.

When Kwashiorkor does occur in the United States, it is usually a sign of child abuse and severe neglect.”

Kwashiorkor and the OIG Work Plan

In fulfillment of the Work Plan, the OIG has completed several hospital audits that found that hospitals had incorrectly billed Medicare inpatient claims with Kwashiorkor.

In the audit reports, the OIG indicates that Kwashiorkor generally affects children and the Medicare program is primarily provided to people age 65 or older. Yet, “for calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis for Kwashiorkor. Therefore, we are conducting a series of reviews of hospitals with claims that include this diagnosis code.”

Key Takeaways from 2014 OIG Reports:

• Consistent in the findings for all of the hospitals was that almost all claims reviewed did not comply with Medicare requirements for billing Kwashiorkor in that they used code 260 but should have used codes for other forms of malnutrition. In several instances removing code 260 did not result in a DRG change. When it did result in a DRG change it resulted in overpayments being made to the hospital.
• The combined overpayment by Medicare was $2,074,341. This is staggering when you consider that this amount is overpayment for one single secondary diagnosis code at only twelve hospitals.
• The reasons for coding errors sited by the hospitals included:
• Lack of clarity in the coding guidelines,
• Issues with the medical coding software program used to code the diagnosis; and
• Incorrect guidance from a third party consultant.

What Guidance is Available to Hospitals?

To answer the “lack of clarity in coding guidelines” for coding Kwashiorkor here are two resources that hospitals can look to for malnutrition coding guidance.

Coding Clinic

Volume 3, Issue 1 , page 3 of the October 2012 Medicare Quarterly Compliance Newsletter, provides an example of a Recovery Auditor findings where Kwashiorkor had been coded as a secondary major comorbidity incorrectly and refers the reader to Coding Clinic, Third Quarter 2009.

Specifically, Coding Clinic, Third Quarter 2009, p. 6 advises hospitals to only code 263.0 for moderate protein malnutrition as this category also includes protein-calorie malnutrition. Coding Clinic further advises that unless the physician specifically documents Kwashiorkor Code 260 should not be used.

Consensus Statement

The American Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN) published a Consensus Statement in the May 2012 Journal of the Academy of Nutrition and Dietetics.

This article acknowledges that “the diagnosis of malnutrition in a patient is an undeniably complicating condition that in many cases significantly increased resource utilization in the acute care setting beyond that experienced by the patient in nutritional health.”

While hospitals have historically looked to serum albumin and prealbumin levels as an indicator of malnutrition, the Academy’s Evidence Analysis Library (EAL) analysis found that “acute-phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.”

This article also notes that “CMS has also questioned the use of acute-phase serum proteins as primary diagnostic criteria for malnutrition since studies increasingly suggest limited correlation of these proteins with nutritional status.”

The Academy and Aspen state that two of the following six characteristics should be identified in a patient when diagnosing malnutrition:

• Weight loss;
• Loss of muscle mass;
• Loss of subcutaneous fat;
• Localized or generalized fluid accumulation that sometimes mask weight loss; and
• Diminished functional status as measure by hand grip strength
• Insufficient energy intake;

It is advised that these characteristics be assessed at the time of the hospital admission and “at frequent intervals throughout the patient’s stay in an acute, chronic, or transitional care setting.”

The article goes on to site a study by Fry and colleagues that “showed that preexisting “malnutrition and/or weight loss” was a positive predictive variable for all eight major surgery-associated “never events” (inexcusable outcomes in a health care setting.”

Assessment, diagnosis and treatment of malnutrition are critical for the wellbeing of our patients. Equally important is identifying the characteristics that need to be assessed in formulating the correct type of malnutrition (e.g. moderate or severe) diagnosis. This article contains a table with detailed clinical criteria to assist in determining the severity levels of malnutrition and I strongly encourage you to read this article.