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News: OIG sites two San Antonio facilities for Kwashiorkor errors

CDI Strategies, March 5, 2015

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For calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis code for Kwashiorkor, a form of severe protein malnutrition typically found in third-world countries that is extremely rare in the United States. The OIG has vigorously reviewed the high volume of claims for the disease during the past several years, citing many facilities and recouping thousands of dollars. Two San Antonio facilities—Baptist Health System and Methodist Hospital—are the latest to fall under OIG scrutiny.

Baptist received $7,689,318 from Medicare for Kwashiorkor care, according to a recent OIG report. After examining 102 of the 468 inpatient hospital claims, the OIG found that none of the claims were accurate, and that the hospital should have coded for another form of malnutrition or no malnutrition code at all. For its part, Baptist Health pointed to confusing coding requirements and agreed to address the situation.

At Methodist, the OIG found that none of the 124 claims audited met requirements for Kwashiorkor.

“Hospital officials attributed errors to a lack of clarity in the coding guidelines and issues with the medical coding software program used to code the diagnoses,” according to the report. 

CDI professionals can help ensure that physician documentation accurately reflects appropriate malnutrition documentation, and work with physicians and coders to prevent inappropriate Kwashiorkor coding.

AHA’s Coding Clinic for ICD-9-CM, Third Quarter 2009 states that coders should not report ICD-9-CM code 260 when the provider does not specifically document Kwashiorkor. Coding Clinic also states:

“Kwashiorkor … is extremely rare in the United States. The National Center for Health Statistics (NCHS) is considering a proposal to revise the index entries under mild and moderate protein malnutrition in order to provide clearer direction ...”

Editor’s Note: For additional information and recommendations regarding CDI role in capturing malnutrition diagnoses consider reading the following articles:

• Master malnutrition definitions, coding rules
• News: OIG targets Kwashiorkor claims
• News: Maryland facility faces $8 million fraud charges for Kwashiorkor billing
• News: California facilities struggle with allegations of inappropriately billing for kwashiorkor 

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