Malnutrition Denials
We are starting to get some denials regarding malnutrition. Reason for denial for severe protein calorie malnutrition is because patients BMI was not less than 16. We use ASPEN criteria and my appeal is that BMI is not a part of ASPEN. Seems as if denial reason is based on a mixture of ASPEN and WHO criteria because both criteria are referenced in the denial letter. Anyone experience same? Any advice?
Comments
Suggest you view this report : http://go.usa.gov/x962B. This is a link to a recent OIG incident with an excellent site rebuttal.
Paul Evans, RHIA, CCDS
As a Coder and CDI Professional for over 25 years I am very disturbed how Payers can dictate how we code based on their own set of rules and guidelines that often have no merit.
Thank you for the opportunity to read such an impressive letter (Rebuttal).
Jill Benjamin-Gill, CCS, CCDS, CDIP
Jill. I concur 100% and many in the CDI profession face such issues regarding denials. I, too, believe, we need to issue a rebuttal, if appropriate.
Paul Evans, RHIA
If we think it is severe, we make sure the dietician is seeing the patient and puts severe malnutrition in their notes and the evidence of it. We have had denials overturned
Leah Savage, MSN, RN, CCDS
Unfortunately the auditors are going to issue these types of denials along with the respiratory failure one you cited in another post...it's what they do! They twist criteria or make up criteria for their benefit. We've had AKI denied due to "The patient's Cr not rising 3 times from normal/baseline"! Make sure your letters are on time and continue to appeal until you cannot!
Jeff
Jeff: At a certain point, one can only hope Senior Executives take such issue to formal legal process rather than dealing with an auditor that would not accept rationale criteria, such as KDIGO. Judging by comments on our site, this is a common source of frustration 'across the land'.
Paul
Very true Paul!
One thing that needs to be addressed is the myth of normal reference ranges. The specific reference range is much less important than a patients deviation from baseline.
For example, if your baseline BP runs 90/45 (like my wives does), you are not really hypotensive at a bp of 88/43. However if your normal BP (untreated) runs 180/90 (like mine does) you could actually be having elevated lactate levels and signs of shock with a bp of 100/60, at least until your body compensates and readjusts.
To wit.....an absolutely value setting of BMI for a measurement of malnutrition is just wrong. Plain and simple, period, there really is no debate.
One person can be severely malnourished with a BMI of 23 (if their baseline was 35) while another person may actually not be malnourished with a BMI of 16 (if their baseline was 17). The number by itself is meaningless...as are most lab values and diagnostic criteria, without putting it into the context of the patient.
To prove the point further, read the entire KDIGO paper....it says you can have AKI while still falling within the normal "reference range" if you have a moderate deviation (onset within 48 hours) from your baseline levels (if known). Having an AKI while still being in the normal reference range sounded strange to me so I ran it by an nephrologists and found out sure enough...that is a legitimate diagnosis based on a known baseline of the patients functioning (pretty much ignoring the "normal reference ranges").
I think one day soon we will learn that "normal reference ranges" are basically garbage as diagnostic criteria, little more than a starting point when we have a completely unknown patient and unknown clinical scenario.