Malnutrition Denials

Dear Colleagues, We face several denials for the diagnosis severe protein calorie malnutrition as the RAC requires all 4 WHO criteria be met. Our metabolic specialists renounce this, stating WHO is antiquated and instead point to ASPEN criteria including an element of inflammatory process to be present (CRP, sed rate, wbc)as the 'gold standard' for assessing for severe protein calorie malnutrition. Could you please comment: A. do you have frequent denials for severe protein calorie malnutrition, B. what nutritional status criteria is used at your institution?
Thank you, Melanie Halpern, Coordinator, CDS Program, Atlantic Health System--Morristown Medical Center, Morristown, NJ

Comments

  • edited May 2016
    I suspect this will not be of much help. We use ASPEN criteria but unfortunately we are not provided any denials information so I don't know if we have incurred any denials on this diagnosis. We have requested denials information but still a work in progress.

    Debbie Smith RN, CCDS,CCS


  • edited May 2016
    Thanks for the feedback Debbie


  • What is your process to deal with denials?

    Who writes rebuttal? I helped write letter-and it was reversed. Citing what "most up to date research shows"/evidenced bases research... Sent two supporting articles: ASPEN consensus statement and an article from?JAHCO on effects of under diagnosed malnutrition.

    At 2014 conference there was a RAC appeal presentation (you can find under 2014 archives) that was where I got the sending two supporting articles. Current facility does not have physician champion, but if you do... Write letter, include articles and have MD consign (all in that presentation). If you need help with the supporting articles, can send to you tomorrow, if you can list email.

    Ann


  • edited May 2016
    Sincere thanks Ann.
    My work email is
    Melanie.halpern@atlantichealth.org

    Would really appreciate your insight and support.
    Thank you very much!

    Melanie


    >
  • edited May 2016
    We review all coding denials along with coding to determine whether to
    appeal or not.

    We do appeal the majority of denials and definitely utilize our
    organizational clinical guidelines and research of the literature in the
    defense of coded diagnoses.

    Sometimes we involve our physician advisors or the attending physician
    to review and sign the letters. It has been effective with the attending
    doctor as well as the Physician Advisor.

    The people denying can sound very assured about their use of coding
    clinics or literature but often there are additional coding clinics and
    literature to refute their findings.

    Definitely recommend CDI getting involved with denials.

    Maureen Dion-Perry
    Clinical Documentation Program Resource
    Marshall Medical Center
    Placerville, CA 95667


  • edited May 2016
    forgot to mention that we use Aspen criteria also and they have worked
    with malnutrition denials.

    Maureen Dion-Perry
    Clinical Documentation Program Resource
    Marshall Medical Center
    Placerville, CA


  • edited May 2016
    Thank you Maureen!
    Melanie


    >
  • Hi, We have recently received a denial by Humana for severe malnutrition stating that the patient did not meet their criteria. After we appealed and it was evident  that the patient did meet criteria and that it was documented, the next letter stated that "there was no clinically significant resource consuming indication for acute intervention beyond routine care such as enteral or TPN. There was no central line placement for or feeding tube placement and that oral supplements are typically over the counter and are often provided in the home. 
    So basically, they are requiring TPN or feeding tube insertions. I don't even know how to respond to this. Any suggestions?
  • https://www.malnutritionpathway.co.uk/mal-overview
    This was a neat sight that gave multiple treatment options. I often find that severe malnutrition is a direct result of another medical condition, such as cancer, COPD, dementia, etc. Sometimes, treatment is not appropriate for example, if the patient is end of life and on comfort measures. That does not mean that it was not evaluated by the physician and taken into consideration for placing the patient on comfort measures. Coding guidelines allow inclusion of secondary diagnoses if they require monitoring, evaluation, treatment, additional nursing care, or extends the length of stay. Another great reference I came across:
    https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Documenting-Malnutrition-November-17.pdf

  • Thank you very much!
  • Dear Colleagues, We face several denials for the diagnosis severe protein calorie malnutrition as the RAC requires all 4 WHO criteria be met. Our metabolic specialists renounce this, stating WHO is antiquated and instead point to ASPEN criteria including an element of inflammatory process to be present (CRP, sed rate, wbc)as the 'gold standard' for assessing for severe protein calorie malnutrition. Could you please comment: A. do you have frequent denials for severe protein calorie malnutrition, B. what nutritional status criteria is used at your institution? Thank you, Melanie Halpern, Coordinator, CDS Program, Atlantic Health System--Morristown Medical Center, Morristown, NJ

    We use ASPEN criteria.  Yes, we get a ton of malnutrition denials.  All of which are supported by ASPEN and meet the definition of a secondary diagnosis.  Very hard to overturn them. 
  • We use ASPEN criterion in our appeals.  Additionally, I look for information to dispute the reviewer's findings such as there was no reported weight loss, but the patient has dementia and interview may not be accurate.  Poke holes in what you can find.  Also, I would submit a letter from your metabolic specialists that are disputing WHO criterion with your appeal. 
  • Hi, We have recently received a denial by Humana for severe malnutrition stating that the patient did not meet their criteria. After we appealed and it was evident  that the patient did meet criteria and that it was documented, the next letter stated that "there was no clinically significant resource consuming indication for acute intervention beyond routine care such as enteral or TPN. There was no central line placement for or feeding tube placement and that oral supplements are typically over the counter and are often provided in the home. 
    So basically, they are requiring TPN or feeding tube insertions. I don't even know how to respond

    The issue is with the medical necessity criteria product they are applying (InterQual, Milliman, etc.). Years ago, I asked AHA Coding Clinic about this issue (resource consumption in code assignment or sequencing) and AHA stated that is not a coding concept (its Medical Necessity/Utilization management) and therefore not a criteria for coding. Now you can say that there is ‘resource consumption’ inherent in the coding criteria (principal diagnosis and additional diagnosis assignment criteria), but code assignment is not based on ‘resource consumption’ according to UHDDS definitions or Official Coding Guidelines. Was the malnutrition the principal or additional diagnosis? Was this a matter of admission type? Two thoughts: first I would counter with UHDDS/Coding Guidelines and ‘quality of care’ (level of treatment was appropriate and did consume resources; affected patient care, etc.). Second, was the degree of malnutrition still severe, or was there evidence that treatment was effective and a different degree should be documented and coded? Lastly, it’s very important for CDI to work closely with the Utilization department for denial prevention; ask if they have the InterQual or Milliman (or whichever they use) references and familiarize yourself with them.


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