Article Detail - JF Part A

In light of the 2020 OIG Report, "Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims," CMS is reminding hospital billing staff to make sure that they are correctly coding severe malnutrition diagnoses and codes according to the patient’s medical record for the inpatient stay.

Nutritional marasmus (diagnosis code E41) and unspecified severe protein-calorie malnutrition (diagnosis code E43) are two types of severe malnutrition listed in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Nutritional marasmus is a form of serious protein-energy malnutrition that is caused by a deficiency in calories and energy and is found primarily in children. Previous Office of Inspector General (OIG) audits of severe malnutrition found that hospitals had incorrectly billed Medicare by using severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all. Diagnosis codes E41 and E43 (collectively referred to in the OIG report as "severe malnutrition diagnosis codes") are classified as a type of major complication or comorbidity (MCC). Adding MCCs to a Medicare claim can result in a higher Medicare payment.

For a claim to be submitted with severe malnutrition diagnosis codes, the corresponding patient medical record documentation must show evidence that the malnutrition was severe. Otherwise, codes for other forms of malnutrition should be used, or no malnutrition diagnosis codes should be used at all.

ICD-10-CM Official Guidelines for Coding and Reporting provides general rules for reporting other diagnosis codes. These guidelines state that diagnosis codes can be billed for additional conditions if those conditions affect patient care in terms of requiring clinical evaluation, therapeutic treatment, or diagnostic procedures or if those conditions extend the length of the hospital stay or require increased nursing care or monitoring. Previous conditions that have no impact on the current stay should not be reported.

For additional information on Inpatient Claim Diagnosis Reporting, see IOM 100-04 Medicare Claims Processing Manual, Chapter 23, Section 10.2.