Hospitals will continue to see Medicare denials for severe protein-calorie malnutrition when reviewers aren’t convinced the code is accurate or the clinical evidence supports it, experts say. There’s a Catch-22 because registered dieticians evaluate patients for malnutrition, but malnutrition can’t be coded unless physicians diagnose it, and they may not review the notes of the registered dieticians. Hospitals are trying to bridge that gap with smart phrases and other strategies.

Hospitals are already in a malnutrition billing pressure cooker. It was the focus of a July report^[1] from the HHS Office of Inspector General (OIG), which estimated that hospitals overcharged Medicare $1 billion by incorrectly assigning two malnutrition diagnosis codes—nutritional marasmus (E41) or unspecified severe protein-calorie malnutrition (E43) as the sole major comorbid condition or complication—on inpatient claims. OIG recommended that CMS and hospitals split the job of repaying Medicare, with CMS recouping money from the reopening period and instructing providers to follow suit under Medicare’s 60-day refund rule.