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Inpatient Malnutrition: Identify, Implement, Assess and ValidateGISELE LEBLANC, MS, RDN, LDN, CNSC, FAND

March, 2018

Disclosures

No disclosures to report

Objectives

• Identify the essential components of implementing and monitoring the malnutrition coding process.

• Establish a quality assessment process to demonstrate patient outcomes from the implementation of the malnutrition coding process.

• Demonstrate the financial outcomes for C-Suite executives.

Why is this necessary?

Scope of the Problem

1/31 in 3 hospitalized patients is

malnourished upon admission

15-60% Estimated prevalence of

malnutrition in the hospital

Malnutrition leads to adverse outcomesRisk for Pressure Ulcers & Impaired Wound Healing

Immune Suppression

Increased Infection Rate

Muscle Wasting and Functional Loss Falls

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Malnutrition leads to adverse outcomesLonger Lengths of Stay : 12.6 days versus 4.4 days

Higher Readmission Rates: 23% versus 14.9%

Higher Treatment Costs: Direct & Indirect cost: $157 billion each year

Mortality: 5 times more common

Estimated Cost of Malnutrition - State

State Results (90% Confidence Interval) $

Per Capita Cost $ Results (65+) $ Per Capita Cost (65+) $

Massachusetts 322,609,120 47 90,326,104 88

Vermont 29,008,612 45 9,114,263 85

Florida 1,061,692,992 52 346,982,176 91

New York 1,025,842,688 51 28,918,304 90

California 1,779,335,552 44 492,571,488 97

Maryland 340,440,992 55 84,344,672 102

National 15,598,520,320 48 4,320,378,880 93

Simulation annual for 8 target diseases

Massachusetts DAM by disease (Million $)

Stroke COPD CHF Colon Cancer

Breast Cancer

Dementia Musculo-skelatal

Depression Total

$23.4 $35.7 $11.7 $3.8 $1.8 $177.9 $16.6 $51.8 $322.6

Identify & Diagnose• Patient is identified as malnourished or at nutrition risk

via a validated nutrition screen tool

• Referral is made to the RDN

• RDN performs thorough nutrition assessment and determines the degree of malnutrition.

Validated Nutrition Screening ToolThe Joint Commission

PC.01.02.01 The hospital assesses and reassesses its patients.

1. The hospital defines, in writing, the scope and content of screening, assessment, and reassessment in formation it collects. Note 3: The scope may also address the need for more in-depth assessments, such as a nutritional, functional, or pain assessment for patients who are at risk.

2. The hospital has defined criteria that identify when nutritional plans are developed.

DNV Healthcare

NS.3 Nursing staff shall complete an assessment of a patient’s condition within twenty four hours of admission to an inpatient setting.

SR.2a The nursing assessment will include but not be limited to: Dietary requirements.

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Validated Nutrition Screening Tool

SensitivityTRUE POSITIVES

Identified at risk AND is at nutrition riskFALSE POSITIVES

Identified at risk BUT is not at nutritional risk

SpecificityTRUE NEGATIVES

Not identified at risk AND not atnutritional risk

FALSE NEGATIVESNot identified at risk BUT at nutritional risk

Tool Population Sensitivity % Specificity %

Malnutrition Screening Tool (MST)

Acute hospitalized n=408 93 93

Acute hospitalized n=2211 74 76

Malnutrition Universal Screening Tool (MUST)

Hospitalized – med/surgn=995

61 76

Nutrition Risk Screening (NRS 2002)

Hospitalized- med/surgN=995

62 93

Acute hospitalized n=120 70 85

Validated Nutrition Screening ToolConsider the # of criteria that make up the tool:

- Weight Loss - Housebound

- Weight - Impaired general condition

- Height - Meal preparation habits and eating alone

- Appetite - Dementia and depression

- Subcutaneous fat loss - Food intake or eating problem

- Ability to eat and retain food - Intake of fluid/fruits and vegetables

- How and when to administer the tool?

- Involve interdisciplinary collaboration

Identify & Diagnose• Patient is identified as malnourished or at nutrition risk

via a validated nutrition screen tool

• Referral is made to the RDN

• RDN performs thorough nutrition assessment and determines the degree of malnutrition.

Identify & Diagnose• RDN notifies physician of recommended diagnosis with

supporting evidence.

• Physician documents the degree of malnutrition. The clinical documentation specialist will query the physician.

• Coders translate the malnutrition diagnosis from the physician documentation into the corresponding ICD-10 code.

Understanding Malnutrition CodingWhat are ICD-10 codes?

• ICD-10 CM stands for International Classification of Disease, 10th Revision, Clinical Modifications. These are 3-5 digit codes that are used to translate medical documentation, including signs, symptoms, injuries, diseases, and conditions into diagnosis codes.

Understanding Malnutrition CodingWhat are DRGs?

Hospital payment is determined by Medicare Diagnostic Related Groupings (DRGs). Accurate malnutrition documentation and coding not only helps increase hospital revenue, it helps paint a better picture of causes of mortality and morbidity.

ICD10 codes are associated with DRGs. The final primary diagnosis at discharge is the one that determines the DRG to which the patient’s hospital admission is assigned. To maximize the DRG reimbursement, all appropriate ICD10 diagnosis should be entered in the coding database.

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Understanding Malnutrition CodingWhat is meant by Complication or Comorbidity (CC) and Major Complication or Comorbidity (MCC)?

Complications arise after a patient is admitted to the hospital and Comorbiditiesare conditions that were present on admission.

The presence of these diagnosis increase the severity of illness and therefore increase the cost necessary to treat the patient. The more severe complications and comorbidities are considered MCCs.

Understanding Malnutrition CodingWhat does MS-DRG mean?

Medicare Severity-Diagnosis Related Groupings (MS-DRGs) is the system Medicare uses to capture the comorbidities and complications (CCs) and Major Comorbidities and complications (MCCs) conditions on all patients when these conditions are present.

Most primary diagnoses are associated with 3 tiers (commonly known as a triplet):◦ DRG without CC or MCC◦ DRG with CC◦ DRG with MCC

ICD-10 Diagnosis ICD-10 Code Number

Criteria

Kwashiorkor E40 Nutritional edema with dyspigmentation of skin and hair

Marasmus E41 Nutritional atrophy; severe malnutrition otherwise stated; severe energy deficiency

Unspecified severe protein-calorie malnutrition

E43 Applicable to starvation edema; Severe malnutrition due to Type 1 & Type 2 DM; Several protein calorie malnutrition.

Marasmic kwashiorkor E42 Severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus

Moderate protein-calorie malnutrition

E44.0 No definition given.

Mild protein-calorie malnutrition

E44.1 No definition given.CC

ICD-10 Diagnosis ICD-10 Code Number

Criteria

Retarded development following protein-calorie malnutrition

E45 Nutritional dwarfism; Physical retardation due to malnutrition

Unspecified protein calorie malnutrition

E46 A disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food. An imbalanced nutritional status resulting from insufficient intake of nutrients to meet normal physiologic requirement. Inadequate nutrition resulting from poor diet, malabsorption, or abnormal nutrient distribution. The lack of sufficient energy or protein to meet the body’s metabolic demands, as a result of either an inadequate dietary intake or protein, intake of poor-quality dietary protein, increased demands due to disease, or increased nutrient losses.

Implement - Establish Malnutrition Criteria

The article was jointly published by the Academy and JPEN and online versions are available.

Implement - Establish Malnutrition Criteria Energy Intake

Weight Loss

Loss of Subcutaneous Fat

Muscle Loss

Fluid Accumulation

Reduced Grip Strength

In the Context of:

- Acute Illness or Inury

- Chronic Illness

- Social or Environmental Circumstances

.

Parameters are established for Severe and Non-Severe (Moderate) Malnutrition for each of the clinical characteristics and within each of the context.

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Why?

Criteria Severe Moderate Mild

Albumin and/or Prealbumin

<2.0<5.0

<2.5<10.0

<3.0<15.0

Ideal Body Weight <70% <80% <90%

Usual Body Weight <75% wt loss parameters*

<85% >95%

BMI <16 <17 <18.5

* Unintended weight loss of >5% in one month, >7.5% in three months, >10% in 6 months, or >20% in one year.

Understanding Malnutrition CodingHow is payment determined?

That hospital‘s base rate for Medicare payments for that fiscal year (changes every October 1).

Relative Weight (RW) of the Final MS-DRG assigned at discharge (available on www.cms.gov). Be sure to use the correct fiscal year).

◦ Payment = Base rate x RW*

Understanding Malnutrition CodingExample: MS-DRG Example MS-DRG Relative Weight

(RW)Average Payment for US hospitals for CHFbased on MS-DRG

(Base rate of $8,800)

DRG without CC or MCC

293 – Heart failure & shock w/o CC or MCC

0.6732 $5,924

DRG with CC but without MCC

292 – Heart failure & shock w/ CC

0.9610 $8,456

DRG with at least one MCC

291 – Heart failure & shock w/MCC

1.4825 $13,046

Additional factors that affect payments: penalties and incentives

Relative Weight Table

Tracking and Quantifying Payment• Work with Coding Specialist and Billing Department to establish how this can be tracked to measure the financial impact and/or patient outcomes

• Track your current year incremental volume/revenue

• Use the information to create a baseline

• Work with administration, finance and coding to project incremental volumes/revenues for the upcoming fiscal year

Facility’s base rate for Medicare payments for the current fiscal year• Suggested departments to ask:

• Patient Financial Services

• Revenue Integrity

• Patient Billing Office

• Revenue Cycle Office

All patients coded for malnutrition in the previous year using the ICD-10 malnutrition codes.• For those patients, you also want to know:

• Payment source (Medicare, private insurance, Medicaid etc..)

• Final MS-DRG

• Which malnutrition code was assigned (ICD-10)

• If severe E43 – were any other MCCs assigned to that patient?

• If mild E44.1 or moderate E44 – were any MCCs or other CCs assigned to that patient?

If not included in the data from the hospital, use the CMS table for relative weights for each MS-DRG to determine the RW for that MS-DRG. Be sure to use the current year.

Checklist of Data Required to Track Impact

W MCC

or CC

W

MCC

W

CC

W/O

MCC

date

range

match

supplied

month

supplied

date PPX DX2 SPX PT ID MRNO PT TYPE CASE LOS

ADM

DATE D/C DATE

D/C

YEAR

D/C

MONTH CMI

DRG

CODE DRG DESC

PRIN

DIAG CD PRIN DIAG DESC

DX2

CODE

DX3

CODE

DX4

CODE

DX5

CODE

DX6

CODE

1 1 0 0 NO Jan 0 0 1 Inpatient 1 8 8/5/2015 8/13/2015 2015 AUGUST 1.5625 698 OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC 996.64 React-indwell urin cath 038.42 038.49 995.92 038.9 707.03

1 1 0 0 NO Jan 0 0 1 Inpatient 1 22 6/23/2015 7/15/2015 2015 JULY 1.9195 314 OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC 999.32 Blood inf dt cen ven cth 038.49 262 514 557.1 518.82

1 0 1 0 NO Jan 0 0 1 Inpatient 1 5 8/22/2015 8/27/2015 2015 AUGUST 1.617 671 URETHRAL PROCEDURES W CC/MCC 996.76 Comp-genitourin dev/grft 189.0 263.0 197.0 599.0 427.31

1 0 1 0 NO Jan 0 0 1 Inpatient 1 4 4/27/2015 5/1/2015 2015 MAY 1.1235 598 MALIGNANT BREAST DISORDERS W CC 174.9 Malign neopl breast NOS 197.0 511.81 263.0 196.3 423.9

1 1 0 0 NO Jan 0 1 1 Inpatient 1 7 8/20/2015 8/27/2015 2015 AUGUST 1.5131 865 VIRAL ILLNESS W MCC 075 Infectious mononucleosis 262 284.19 784.7 V14.0

1 1 0 0 NO Jan 0 1 1 Inpatient 1 3 4/14/2015 4/17/2015 2015 APRIL 1.9749 146 EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC 146.9 Malig neo oropharynx NOS 262 518.83 V44.0 197.0 401.0

1 1 0 0 NO Jan 0 1 1 Inpatient 1 11 7/21/2015 8/1/2015 2015 AUGUST 2.0182 374 DIGESTIVE MALIGNANCY W MCC 152.0 Malignant neopl duodenum 262 197.7 276.51 537.3 518.0

1 1 0 0 NO Jan 0 1 1 Inpatient 1 7 7/7/2015 7/14/2015 2015 JULY 3.661 166 OTHER RESP SYSTEM O.R. PROCEDURES W MCC 162.2 Malig neo main bronchus 262 428.31 799.4 423.8 511.9

1 1 0 0 NO Jan 0 1 1 Inpatient 1 11 5/20/2015 5/31/2015 2015 MAY 1.6869 180 RESPIRATORY NEOPLASMS W MCC 197.0 Secondary malig neo lung 262 518.81 038.9 584.9 198.89

1 1 0 0 NO Jan 0 1 1 Inpatient 1 2 5/14/2015 5/16/2015 2015 MAY 1.3944 637 DIABETES W MCC 250.12 DMII ketoacd uncontrold 262 V62.84 296.50 536.3 250.62

1 1 0 0 NO Jan 0 1 1 Inpatient 1 11 6/27/2015 7/8/2015 2015 JULY 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.0 Hyperosmolality 262 288.00 294.21 285.9 295.30

1 1 0 0 NO Jan 0 1 1 Inpatient 1 9 5/21/2015 5/30/2015 2015 MAY 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.1 Hyposmolality 262 785.59 348.1 780.39 710.0

1 1 0 0 NO Jan 0 1 1 Inpatient 1 2 7/1/2015 7/3/2015 2015 JULY 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.1 Hyposmolality 262 275.2 273.8 783.21 V85.1

1 1 0 0 NO Jan 0 1 1 Inpatient 1 9 7/2/2015 7/11/2015 2015 JULY 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.1 Hyposmolality 262 295.30 296.20 295.90 783.0

1 1 0 0 NO Jan 0 1 1 Inpatient 1 7 7/18/2015 7/25/2015 2015 JULY 4.9968 981 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC 276.1 Hyposmolality 262 785.50 584.9 576.4 799.4

1 1 0 0 NO Jan 0 1 1 Inpatient 1 5 4/8/2015 4/13/2015 2015 APRIL 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.51 Dehydration 262 196.9 141.0 112.0 787.01

1 1 0 0 NO Jan 0 1 1 Inpatient 1 2 6/3/2015 6/5/2015 2015 JUNE 1.1044 640 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 276.51 Dehydration 262 458.9 276.2 284.11 174.9

1 1 0 0 NO Jan 0 1 1 Inpatient 1 13 8/5/2015 8/18/2015 2015 AUGUST 1.2829 811 RED BLOOD CELL DISORDERS W MCC 282.62 Hb-SS disease w crisis 262 453.86 790.7 997.79 536.2

Relative Weight

DRG

Primary Diagnosis

Secondary Diagnosis

Malnutrition Codes are highlighted

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Patient

Account

Number

DRG

Code

ICD-10-

CM Any

Diag

Coded

Sequenc

e

ICD-10-

CM Diag

Code

ICD-10-CM Diag

Name

Discharge

Date What it would be without Pro/cal malnut weight Actual DRG

Actual

weight

Differenc

e

Multiplied

by Base

Rate

682 2 E43 Unspecified severe protein-calorie malnutrition1/6/2016 MCC RENAL FAILURE W CC 0.9406 RENAL FAILURE W MCC 1.5085 0.5679 3263.256

602 2 E43 Unspecified severe protein-calorie malnutrition1/6/2016 MCC CELLULITIS W/O MCC 0.8429 CELLULITIS W MCC 1.4371 0.5942 3414.38

385 2 E43 Unspecified severe protein-calorie malnutrition1/18/2016 MCC INFLAMMATORY BOWEL DISEASE W CC 0.9996 INFLAMMATORY BOWEL DISEASE W MCC 1.7195 0.7199 4136.675

640 2 E43 Unspecified severe protein-calorie malnutrition1/19/2016 MCC MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC 0.7221 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 1.1318 0.4097 2354.21

252 2 E43 Unspecified severe protein-calorie malnutrition1/21/2016 MCC OTHER VASCULAR PROCEDURES W CC 2.6028 OTHER VASCULAR PROCEDURES W MCC 3.2872 0.6844 3932.686

947 2 E43 Unspecified severe protein-calorie malnutrition1/26/2016 MCC SIGNS & SYMPTOMS W/O MCC 0.7356 SIGNS & SYMPTOMS W MCC 1.1323 0.3967 2279.51

329 2 E43 Unspecified severe protein-calorie malnutrition1/29/2016 MCC MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 2.5511 MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC 5.0709 2.5198 14479.22

Sample of partial data collection spreadsheet

Assess – Importance of NFPA

Academy Malnutrition Resources

http://www.eatrightpro.org/resource/career/professional-development/face-to-face-learning/nfpe-workshop

Cleveland Clinic: Learn to Diagnose Malnutrition Workshop

http://www.clevelandclinicmeded.com/live/courses/malnutrition/

A.S.P.E.N. Malnutrition Toolkit www.nutritioncare.org

Certificate of Training in Adult Malnutrition (Abbott Nutrition Health Institute) http://anhi.org/malnutrition-ce

Malnutrition Severity Assessment Dashboard

Image from: CMS.gov

Hospitals are measured on Quality

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eCQMs

Infographic source: eCQI Resource Center https://ecqi.healthit.gov/ecqms

eCQMs

eCQI Resource Center https://ecqi.healthit.gov/ecqms

Proposed Malnutrition eCQMs

Completion of a malnutrition screening within 24 hours of admission

Completion of a nutrition assessment for patients identified as at-risk for malnutrition within 24 hours of a malnutrition screening

Nutrition care plan for patients identified as malnourished after a complete nutrition assessment

Appropriate documentation of malnutrition diagnosis

What is the Malnutrition Quality Improvement Initiative (MQii)?

41

MQii Objectives

● Develop malnutrition quality measures “that matter”

● Improve malnutrition care with an interdisciplinary care team

roadmap (toolkit)

● Advance tools that can be integrated into EHR systems to improve

care quality

The MQii is focused on older adults (ages 65 and older) given the

significant impact malnutrition has on this patient population and the

opportunity to improve care among these patients

The MQii Uses a Toolkit to Support Improved Malnutrition Care

The Toolkit provides a clear workflow, as well as associated tools and resources, to support quality improvement and best practices in the screening, assessment, and treatment of older adults admitted to the hospital with or at risk of malnutrition.

http://mqii.defeatmalnutrition.today/mqii-toolkit.html

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MQii Tools

Setting up data collection Setting up data collection

Metrics to Track:

(if without electronic monitoring)

1. Gather data on your current nutrition screening tool.

2. Keep specific patient population or units separate.

3. Perform random evaluation of screening.

4. Gather information on break in process.

Report/Validate the DataFacility Bed Size Date Reported Revenue Collected Comments

Hospital A 614 9 months in 2014 $580,000

2015 $1.2 M

2016 $2.1 M

Hospital B 95 7 months in 2015 $290,000

Hospital C 50 2015 $170,000

Hospital D 250 2016 $320,141

Hospital E 150 2016 $213,526 Medicare only MCC

2017 $295,922 Medicare only MCC January February March April May June July August Sept October November December

2016 $161,764.00 $182,556.00 $228,129.00 $152,178.00 $197,359.00 $219,347.00 $172,553.00 $221,000.00 $182,377.00 $247,222.00 $190,143.00 $213,526.00

2017 $209,721.00 $216,777.00 $208,455.00 $228,984.00 $247,616.00 $256,943.00 $256,342.00 $246,308.00 $276,097.00 $310,786.00 $283,205.00 $295,922.00

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

2016 2017 Linear (2016) Linear (2017)

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Tracking and Quantifying Payment

$0.00

$50,000.00

$100,000.00

$150,000.00

$200,000.00

$250,000.00

$300,000.00

1 2 3 4 5 6 7 8 9 10 11 12MONTHS

Incremental Revenue YTD

Target

Tracking and Quantifying Payment

Validating & Tracking: Continued • Audit denials can occur after the bill is submitted• Auditors can claim inadequate documentation for ICD-10 code described at

discharge• Denial of coding is reported to the facility’s coding department• Ask that the coders contact you with all malnutrition denials• Conduct regular chart audits and evaluate the appropriateness of the

malnutrition diagnosis.• Check for any diagnosis that may trigger a red flag such as:

• Kwashiorkor (E40)• Marasmus (E41)• Marasmic kwashiorkor (E42)

Tracking

Tracking: Quality Indicators Outcomes• Average length of stay for patients receiving malnutrition care since

implementation

• Readmission rate of patients receiving malnutrition care since implementation

• Percentage of patients diagnosed with Malnutrition following NFPA training

ConclusionOutcomes show the true picture!

It’s imperative to measure outcomes with new interventions to demonstrate the impact.

Clinical dietitians can demonstrate their value by demonstrating both patient and financial outcomes.

There are many resources to assist you.

Take advantage of any technology you have at your disposal.

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ReferencesFontes D Clin Nutr 2014;33: 291-295

Tappenden K et al. JPEN 2013;37:482-497

White J et al. JAND 2012;112:730-738

Barker et al. Int J Environ Res Public Health. 2011;8(2):514-527

Fry DE et al. Arch Surg. 2010; 145(2):148-151

Corkins M et al. JPEN 2014;38:186-195

Fingar R et al. 2016; HCUP Statistical Brief #218 https://hcup-us.ahrq.gov/reports/statbriefs/sb218-Malnutrition-Readmissions-2013.jsp

Goates S et al. JPEN 2014;38(2):77S-85S

ReferencesMogensen K et al. JPEN 2017;00:1-9 http://onlinelibrary.wiley.com/doi/10.1177/0148607117709766/pdf

Hudson L et al. JPEN 2018;00:1-6 http://onlinelibrary.wiley.com/doi/10.1002/jpen.1021/epdf

Elia M et al. Clin Nutr 2005;24:867-884

Skipper et al. JPEN 2012;36:292-298

Phillips W. Support Line 39;3, June, 2017

White J et al. JAND 2012;112:730-738