Health Information Management

News: OIG targets Kwashiorkor claims

CDI Strategies, February 13, 2014

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Christus Saint Vincent Regional Medical Center, in Santa Fe, used ICD-9-CM diagnosis code 260 for Kwashiorkor, when it should have used codes for other forms of malnutrition, according to a report from the Office of the Inspector General (OIG), released in January. In a separate report, the OIG investigated $3,189,884 in Kwashiorkor-related claims from Des Moines-based Mercy Health Network.

 
Kwashiorkor is a form of severe protein malnutrition which typically afflicts children in so-called “third-world” countries during famine and is particularly rare in the United States. However, during calendar years 2010 and 2011 Medicare paid more than $700 million for Kwashiorkor-related claims.  
 
Of the 115 claims the OIG reviewed at Christus Saint Vincent, reassignment of the code to one reflecting the more appropriate diagnosis did not result in a change in reimbursement. However, nearly 90 claims did result in an overpayment of nearly $150,000 which the facility agreed to refund.
 
In its response to the OIG report, Christus Saint Vincent officials indicate that the errors were due to software issue related to its coding software, and that the system had been updated to strengthen controls over the billing of Kwashiorkor in 2010, but that the correction did not immediately take hold.
 
“By 2011 however, these billing errors were reduced to two and neither of those resulted in an overpayment,” hospital officials wrote. “Christus Saint Vincent also conducted a follow up review and verified that there have been no additional inpatient Medicare claims submitted with code 260  (Kwashiorkor) through September 30, 2013.”
 
In the Mercy Health Network study, out of 102 claims reviewed by the OIG only 14 resulted in an overpayment of nearly $90,000. In response to the report, Mercy officials indicated that its endcoder software edit for diagnosis code 260 will pull up the latest Coding Clinic for ICD-9-CM related to Kwashiorkor “to ensure the most current requirements are being met.”

 



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