Why Quashing Kwashiorkor Overpayments is a Good Lesson for Any Payer
If you are seeing claims for the treatment of Kwashiorkor, you may want to conduct a review of each claim containing this diagnosis. In OIG reports filed last month, a review of 305 claims with the diagnosis of Kwashiorkor from three different institutions concluded that 100% of them did not meet billing requirements. This resulted in an overpayment to these institutions of $876,950 in total. Earlier this year, OIG reviewed 891 claims from nine other institutions with this diagnosis, with similar findings of failure to meet billing requirements and an overall overpayment of nearly $1.2 million.
Kwashiorkor is a form of severe malnutrition caused by a lack of protein in the diet. It is a common and widespread disease in developing countries, but rarely occurs in the United States. Signs of the disease include edema, damaged immune system, irritability, flaky rash, extended belly, and shock. Diagnosis is made based upon arterial blood gas, blood urea nitrogen, blood levels of creatinine, blood levels of potassium, urinalysis, and complete blood count. Kwashiorkor can be treated with proper nutrition, but permanent consequences such as below level growth and mental impairment can occur. If Kwashiorkor is not treated, it could lead to coma or death.
Because this one rare diagnosis accounts for a disproportionate share of payments (OIG found that Medicare paid U.S. hospitals $711 million for claims with this diagnosis in the years 2010 through 2011), OIG is reviewing a series of hospital claims with the Kwashiorkor diagnosis. In some cases, the addition of the diagnosis of Kwashiorkor on a claim could increase the DRG payment significantly since the diagnosis is considered high-severity. The ICD-9-CM diagnosis code for Kwashiorkor is 260. In ICD-10-CM, the code is either E40 or E42 depending on whether there is accompanying marasmus, or the wasting of subcutaneous tissue and muscle.
The hospitals in these OIG studies reviewed the findings and agreed that the reviewed claims did not meet billing requirements. Reasons cited by the hospitals were the lack of clarity in coding guidelines for this diagnosis, and that coding software and third party guidance led to the incorrect code being used. OIG determined that in every case reviewed, either a code for a different form of malnutrition should have been used, or that there was not documentation to support a diagnosis of malnutrition at all.
Payers can review claims with the diagnosis of Kwashiorkor on a pre-adjudication basis by identifying every claim with the ICD-9-CM diagnosis code of 260 and requesting supporting documentation. Trends by institution and geographical area can easily be identified when this diagnosis code is isolated. With a nearly 100 percent error rate in this diagnosis as evidenced by the OIG, a 100 percent payer review would seemingly be justified.
Avoid Overpayment - Review Documentation for Outpatient Therapy Claims
