GLIM criteria as basis for UHC denial for SPCM
Hi everyone,
We received our first SPCM denial based on GLIM criteria from UHC, curious to know if anyone else have received any at their facility.
Reviewer Rationale:
A clinical validation review based upon clinical criteria was performed on this claim.
As indicated by Coding Clinic 4th Q 2016, a payer may use a specific clinical definition or set of
criteria when establishing a diagnosis. After reviewing the medical record for clinical validation of
unspecified severe protein calorie malnutrition sufficient supporting documentation was not found
within the submitted medical record to validate this diagnosis.
Although the diagnosis of unspecified severe protein calorie malnutrition is documented in physician
query, sufficient supporting documentation was not found within the medical record to validate this
diagnosis based on clinical criteria.
The following criteria were not supported. The patient had no weight loss greater than 10% within the
past 6 months OR greater than 20% beyond 6 months. The patient's BMI was not less than 20.
Patient did not have severely reduced muscle mass.
Secondary diagnosis code E43 was removed from the claim consistent with the documentation that
was received.
Please reference AHA Coding Clinic 4th Q 2016 pgs. 147-149 which addresses that payors may
require a specific clinical definition/criterion to establish a diagnosis.
Please also reference:
Jensen GL, Cederholm T, Correia MITD, et al. (2019). GLIM Criteria for the Diagnosis of
Malnutrition: A Consensus Report from the Global Clinical Nutrition Community. JPEN J Parenter
Enteral Nutr, Vol 43 (1) 32-40.
Optum has performed a DRG review of the case referenced above. After a thorough review of the
documentation provided by your facility, we've determined that the claim was overpaid.
Cynthia Mead RN CCDS
Northern Arizona Healthcare
cynthia.mead@nahealth.com
Comments
UHC is using GLIM. Our RDs are now incorporating when a patient meets both ASPEN AND GLIM.
Another suggestion is to work with contracts to specify which criteria your hospital is going to use. Hopefully, this can be negotiated into your UHC contract.