Payment Policy: Severe Malnutrition Form

# Payment Policy: Severe Malnutrition
Reference Number: CC.PP.145  
Product Types: All  
Last Review Date: 10/23  

[Coding Implications](Coding Implications)  
[Revision Log](Revision Log)  

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.  

## Policy Overview  
Acute care hospitalizations for severe malnutrition require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner.  

The cost difference between a Diagnosis Related Group (DRG) billed with severe malnutrition as a major complication or comorbidity (MCC) (in a position other than as the primary diagnosis code position) and a DRG billed without severe malnutrition as an MCC (in a position other than as the primary diagnosis code position) will be denied reimbursement unless meeting the documentation requirements described in this policy.  

The purpose of this policy is to perform a retrospective review of claims billed with the diagnosis of severe malnutrition to validate correct coding and medical necessity for inpatient claims billed with a diagnosis of severe malnutrition.  

## Application  
Inpatient facility claims  

  

## Reimbursement Guidelines  
- The Health Plan uses paid claims data and a proprietary clinical algorithm to identify severe malnutrition claims for retrospective audit.  
- When a potential billing error is identified, the Health Plan will request medical records to validate the diagnosis and procedure codes billed on the claim.  
- Once the medical record is received, certified professional coders and registered nurses will clinically validate the documentation to ensure:  
  a. The medical record contains the necessary information;  
  b. The diagnosis code on the claim matches the diagnosis code in the medical record  
  c. The diagnosis billed on the claim is supported by the clinical information in the medical record.  
- Medical record reviews are overseen by the health plan Medical Director.  
- After review of the medical record, the Health Plan will issue an audit determination letter to the provider. The letter will provide a thorough explanation of the determination as well as details for the provider to submit a dispute if they disagree with the determination.  
- The clinical validation review will be completed within 30 days from receipt of medical records.  
- The following explanation codes will be sent to the provider on the Explanation of Payment (EOP) at the conclusion of the review.  

| Explanation Code | Description |
|------------------|-------------|
| iA               | Deny: Medical records not received per previous request |
| iB               | Pay: DRG payment increase after review of medical records |
| iC               | Pay: DRG payment adjustment after review of medical records |
| iE               | Deny: DRG inpatient payment denied after review of records. Observation claim |
| iF               | Pay: Reinstate payment after review of medical records |

## Coding and Modifier Information  
This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2022, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.  

| CPT/HCPCS Code | Descriptor |
|----------------|-------------|
| N/A            | N/A         |

| Modifier | Descriptor |
|----------|-------------|
| NA       | NA          |

| ICD-10 Codes | Descriptor |
|--------------|-------------|
| E43          | Unspecified severe protein-calorie malnutrition |

## Definitions  
### Diagnosis Related Groups (DRG)  
Patient classification scheme that relates the type of patients a hospital treats (case mix) to the costs incurred by the hospital. The case mix consists of 1) severity of illness, 2) prognosis, 3) treatment difficulty, 4) need for intervention; and 5) resource intensity.  

### Major Complication or Comorbidity  
Diagnosis code(s) used by Medicare to assign individual cases to MS-DRGs based on severity of illness.  

### Medicare Severity Related Diagnosis Groups (MS-DRGs)  
Classification of diagnoses according to severity for payment under the Inpatient Prospective Payment System (IPPS). This classification is based on information reported from the hospital: 1) the principal diagnosis, 2) up to 24 additional diagnoses; and 3) up to 25 procedures performed during the hospitalization.  

### Inpatient Prospective Payment System  
A method of reimbursement in which Medicare payments are based on a predetermined, fixed amount. The payment amount for a specific service is based on how that service is classified, for example, diagnosis related groups (DRG) for inpatient services.  

### Additional Information  
NA  

### Related Documents or Resources  
NA  

  
7. Evans DC, Corkins MR, Malone A, et al. The use of visceral proteins as nutrition markers: An ASPEN position paper (published correction appears in Nutr Clin Pract. 2021 Aug;36(4):909). *Nutr Clin Pract*. 2021;36(1):22 to 28. doi:10.1002/ncp.10588  
8. Worthington P, Balint J, Bechtold M, et al. When is parenteral nutrition appropriate? *JPEN J Parenter Enteral Nutr*. 2017;41(3):324 to 377. doi:10.1177/0148607117695251  
9. Association of Clinical Documentation Integrity Specialists (ACDIS). Q & A: documenting and coding severe malnutrition. *CDI Strategies*. 2022;16(11). https://acdis/articles/qa-documenting-and-coding-severe-malnutrition. Accessed September 18, 2023.  
10. Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition - An ESPEN Consensus. *Clin Nutr*. 2015;34(3):335 to 340. doi:10.1016/j.clnu.2015.03.001  
11. Keller U. Nutritional laboratory markers in malnutrition. *J Clin Med*. 2019;8(6):775. Published 2019 May 31. doi:10.3390/jcm8060775  
12. Guideline: on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: World Health Organization; 2013. https://www.ncbi.nlm.nih.gov/books/NBK190328/. Accessed September 19, 2023.  

## Revision History  
| Date       | Change Summary |
|------------|----------------|
| 02/01/2020 | Policy CPP-145 developed. Approved by MPC. |
| 04/30/2021 | Transferred to Centene template and renumbered policy from CPP-145 to CP.MP.212. Minor rewording of criteria with no clinical significance. Condensed background. References reviewed and updated. Approved by CPC. |
| 05/31/2021 | In I.A.5.a and I.B.1.a, added >5% weight loss in one week as a criteria option. In I.B.4, added severe muscle wasting or loss of subcutaneous fat as criteria option. In I.B.5, added severe edema as an option. Deleted I.C.6 as if I.C.3 is met, the neonate doesn't also have to take >21 days to regain birthweight. Approved by CPC. |
| 06/07/2021 | Transferred to Centene template and renumbered from CPP-145 to WC.PP.145, changed LOB in header from “ALL” to “Medicare.” |
| 08/01/2021 | Added all post pay audit details in the “Reimbursement Guidelines” section |
| 02/16/2022 | Removed error in revision log entry from 06/21. Clarified the location of the post pay audit details in the 8/21 revision log entry |
| 04/22     | References reviewed, updated and reformatted. Updated time criteria I.B.2. from “up to 3 months” to “≥ 1 month. |
| 03/23     | Annual review completed. References reviewed and updated. External specialist reviewed. |
| 10/23     | Updated policy number from WC.PP.145 to CC.PP.145. Changed I.A.1.a from 16 kg/m² to 18.5 kg/m². Changed I.A.5.a and I.B.1.a to > 2% weight loss in one week as a criteria option. Removed “albumin <2.4 gm/dL and/or prealbumin <5 mg/dL” from I.A. Added ICD-10 code E43 to coding table. Replaced all instances of “members” with |

## Revision History (continued)  
| Date       | Change Summary |
|------------|----------------|
| 01/2024    | Corrected applicable products from “Medicare” to “All.” |
| 06/2024    | Removed “Medicare” from “application” as the policy applies to all products. |

## Important Reminder  
For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan’s affiliates, as applicable.  

The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures.  

This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time.  

This payment policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This payment policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.  

Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan.  

This payment policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound by the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.  

## Note: For Medicaid  
For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy.  

## Note: For Medicare  
For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at http://www.cms.gov for additional information.  

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