Inpatient Malnutrition:

Transcription

1 Disclosures Inpatient Malnutrition: Identify, Implement, Assess and Validate GISELE LEBLANC, MS, RDN, LDN, CNSC, FAND No disclosures to report March, 2018 Objectives Why is this necessary? Identify the essential components of implementing and monitoring the malnutrition coding process. Establish a quality assessment process to demonstrate patient outcomes from the implementation of the malnutrition coding process. Demonstrate the financial outcomes for C-Suite executives. Scope of the Problem 1/3 1 in 3 hospitalized patients is malnourished upon admission 15-60% Estimated prevalence of malnutrition in the hospital Malnutrition leads to adverse outcomes Risk for Pressure Ulcers & Impaired Wound Healing Immune Suppression Increased Infection Rate Muscle Wasting and Functional Loss Falls 1

2 Malnutrition leads to adverse outcomes Longer Lengths of Stay : 12.6 days versus 4.4 days Higher Readmission Rates: 23% versus 14.9% Higher Treatment Costs: Direct & Indirect cost: $157 billion each year Mortality: 5 times more common Estimated Cost of Malnutrition - State State Results (90% Confidence Interval) $ Per Capita Cost $ Results (65+) $ Per Capita Cost (65+) $ Massachusetts 322,609, ,326, Vermont 29,008, ,114, Florida 1,061,692, ,982, New York 1,025,842, ,918, California 1,779,335, ,571, Maryland 340,440, ,344, National 15,598,520, ,320,378, Simulation annual for 8 target diseases Massachusetts DAM by disease (Million $) Stroke COPD CHF Colon Cancer Breast Cancer Dementia Musculoskelatal Depression Total $23.4 $35.7 $11.7 $3.8 $1.8 $177.9 $16.6 $51.8 $322.6 Identify & Diagnose Patient is identified as malnourished or at nutrition risk via a validated nutrition screen tool Referral is made to the RDN RDN performs thorough nutrition assessment and determines the degree of malnutrition. Validated Nutrition Screening Tool The Joint Commission PC The hospital assesses and reassesses its patients. 1. The hospital defines, in writing, the scope and content of screening, assessment, and reassessment in formation it collects. Note 3: The scope may also address the need for more in-depth assessments, such as a nutritional, functional, or pain assessment for patients who are at risk. 2. The hospital has defined criteria that identify when nutritional plans are developed. DNV Healthcare NS.3 Nursing staff shall complete an assessment of a patient s condition within twenty four hours of admission to an inpatient setting. SR.2a The nursing assessment will include but not be limited to: Dietary requirements. 2

3 Validated Nutrition Screening Tool Tool Population Sensitivity % Specificity % Malnutrition Screening Tool (MST) Malnutrition Universal Screening Tool (MUST) Nutrition Risk Screening (NRS 2002) Acute hospitalized n= Acute hospitalized n= Hospitalized med/surg n=995 Hospitalized- med/surg N= Acute hospitalized n= Validated Nutrition Screening Tool Consider the # of criteria that make up the tool: - Weight Loss - Housebound - Weight - Impaired general condition - Height - Meal preparation habits and eating alone - Appetite - Dementia and depression - Subcutaneous fat loss - Food intake or eating problem - Ability to eat and retain food - Intake of fluid/fruits and vegetables Sensitivity Specificity TRUE POSITIVES Identified at risk AND is at nutrition risk TRUE NEGATIVES Not identified at risk AND not at nutritional risk FALSE POSITIVES Identified at risk BUT is not at nutritional risk FALSE NEGATIVES Not identified at risk BUT at nutritional risk - How and when to administer the tool? - Involve interdisciplinary collaboration Identify & Diagnose Patient is identified as malnourished or at nutrition risk via a validated nutrition screen tool Referral is made to the RDN RDN performs thorough nutrition assessment and determines the degree of malnutrition. Identify & Diagnose RDN notifies physician of recommended diagnosis with supporting evidence. Physician documents the degree of malnutrition. The clinical documentation specialist will query the physician. Coders translate the malnutrition diagnosis from the physician documentation into the corresponding ICD-10 code. What are ICD-10 codes? ICD-10 CM stands for International Classification of Disease, 10th Revision, Clinical Modifications. These are 3-5 digit codes that are used to translate medical documentation, including signs, symptoms, injuries, diseases, and conditions into diagnosis codes. What are DRGs? Hospital payment is determined by Medicare Diagnostic Related Groupings (DRGs). Accurate malnutrition documentation and coding not only helps increase hospital revenue, it helps paint a better picture of causes of mortality and morbidity. ICD10 codes are associated with DRGs. The final primary diagnosis at discharge is the one that determines the DRG to which the patient s hospital admission is assigned. To maximize the DRG reimbursement, all appropriate ICD10 diagnosis should be entered in the coding database. 3

4 What is meant by Complication or Comorbidity (CC) and Major Complication or Comorbidity (MCC)? Complications arise after a patient is admitted to the hospital and Comorbidities are conditions that were present on admission. The presence of these diagnosis increase the severity of illness and therefore increase the cost necessary to treat the patient. The more severe complications and comorbidities are considered MCCs. What does MS-DRG mean? Medicare Severity-Diagnosis Related Groupings (MS-DRGs) is the system Medicare uses to capture the comorbidities and complications (CCs) and Major Comorbidities and complications (MCCs) conditions on all patients when these conditions are present. Most primary diagnoses are associated with 3 tiers (commonly known as a triplet): DRG without CC or MCC DRG with CC DRG with MCC ICD-10 Diagnosis ICD-10 Code Number Criteria Kwashiorkor E40 Nutritional edema with dyspigmentation of skin and hair Marasmus E41 Nutritional atrophy; severe malnutrition otherwise stated; severe energy deficiency Unspecified severe protein-calorie malnutrition E43 Applicable to starvation edema; Severe malnutrition due to Type 1 & Type 2 DM; Several protein calorie malnutrition. Marasmic kwashiorkor E42 Severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus Moderate proteincalorie malnutrition Mild protein-calorie malnutrition E44.0 No definition given. E44.1 No definition given. CC ICD-10 Diagnosis Retarded development following proteincalorie malnutrition Unspecified protein calorie malnutrition ICD-10 Code Number E45 E46 Criteria Nutritional dwarfism; Physical retardation due to malnutrition A disorder caused by a lack of proper nutrition or an inability to absorb nutrients from food. An imbalanced nutritional status resulting from insufficient intake of nutrients to meet normal physiologic requirement. Inadequate nutrition resulting from poor diet, malabsorption, or abnormal nutrient distribution. The lack of sufficient energy or protein to meet the body s metabolic demands, as a result of either an inadequate dietary intake or protein, intake of poorquality dietary protein, increased demands due to disease, or increased nutrient losses. Implement - Establish Malnutrition Criteria Implement - Establish Malnutrition Criteria Energy Intake Weight Loss Loss of Subcutaneous Fat Muscle Loss Fluid Accumulation Reduced Grip Strength In the Context of: - Acute Illness or Inury - Chronic Illness - Social or Environmental Circumstances Parameters are established for Severe and Non-Severe (Moderate) Malnutrition for each of the clinical characteristics and within each of the context. The article was jointly published by the Academy and JPEN and online versions are available.. 4

5 date W MCC W W W/O range supplied supplied ADM D/C D/C DRG PRIN DX2 DX3 DX4 DX5 DX6 or CC MCC CC MCC match month date PPX DX2 SPX PT ID MRNO PT TYPE CASE LOS DATE D/C DATE YEAR MONTH CMI CODE DRG DESC DIAG CD PRIN DIAG DESC CODE CODE CODE CODE CODE NO Jan Inpatient 1 8 8/5/2015 8/13/ AUGUST OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC React-indwell urin cath NO Jan Inpatient /23/2015 7/15/ JULY OTHER CIRCULATORY SYSTEM DIAGNOSES W MCC Blood inf dt cen ven cth NO Jan Inpatient 1 5 8/22/2015 8/27/ AUGUST URETHRAL PROCEDURES W CC/MCC Comp-genitourin dev/grft NO Jan Inpatient 1 4 4/27/2015 5/1/ MAY MALIGNANT BREAST DISORDERS W CC Malign neopl breast NOS NO Jan Inpatient 1 7 8/20/2015 8/27/ AUGUST VIRAL ILLNESS W MCC 075 Infectious mononucleosis V NO Jan Inpatient 1 3 4/14/2015 4/17/ APRIL EAR, NOSE, MOUTH & THROAT MALIGNANCY W MCC Malig neo oropharynx NOS V NO Jan Inpatient /21/2015 8/1/ AUGUST DIGESTIVE MALIGNANCY W MCC Malignant neopl duodenum NO Jan Inpatient 1 7 7/7/2015 7/14/ JULY OTHER RESP SYSTEM O.R. PROCEDURES W MCC Malig neo main bronchus NO Jan Inpatient /20/2015 5/31/ MAY RESPIRATORY NEOPLASMS W MCC Secondary malig neo lung NO Jan Inpatient 1 2 5/14/2015 5/16/ MAY DIABETES W MCC DMII ketoacd uncontrold 262 V NO Jan Inpatient /27/2015 7/8/ JULY MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Hyperosmolality NO Jan Inpatient 1 9 5/21/2015 5/30/ MAY MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Hyposmolality NO Jan Inpatient 1 2 7/1/2015 7/3/ JULY MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Hyposmolality V NO Jan Inpatient 1 9 7/2/2015 7/11/ JULY MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Hyposmolality NO Jan Inpatient 1 7 7/18/2015 7/25/ JULY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC Hyposmolality NO Jan Inpatient 1 5 4/8/2015 4/13/ APRIL MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Dehydration NO Jan Inpatient 1 2 6/3/2015 6/5/ JUNE MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC Dehydration NO Jan Inpatient /5/2015 8/18/ AUGUST RED BLOOD CELL DISORDERS W MCC Hb-SS disease w crisis /28/2018 Why? Criteria Severe Moderate Mild Albumin and/or Prealbumin <2.0 <5.0 <2.5 <10.0 <3.0 <15.0 Ideal Body Weight <70% <80% <90% Usual Body Weight <75% wt loss parameters* <85% >95% BMI <16 <17 <18.5 * Unintended weight loss of >5% in one month, >7.5% in three months, >10% in 6 months, or >20% in one year. How is payment determined? That hospital s base rate for Medicare payments for that fiscal year (changes every October 1). Relative Weight (RW) of the Final MS-DRG assigned at discharge (available on Be sure to use the correct fiscal year). Payment = Base rate x RW* Example: MS-DRG Example MS-DRG Relative Weight (RW) DRG without CC or MCC DRG with CC but without MCC DRG with at least one MCC 293 Heart failure & $5,924 shock w/o CC or MCC 292 Heart failure & shock w/ CC 291 Heart failure & shock w/mcc $8, $13,046 Additional factors that affect payments: penalties and incentives Average Payment for US hospitals for CHF based on MS-DRG (Base rate of $8,800) Tracking and Quantifying Payment Work with Coding Specialist and Billing Department to establish how this can be tracked to measure the financial impact and/or patient outcomes Track your current year incremental volume/revenue Use the information to create a baseline Work with administration, finance and coding to project incremental volumes/revenues for the upcoming fiscal year Relative Weight Table Checklist of Data Required to Track Impact Facility s base rate for Medicare payments for the current fiscal year Suggested departments to ask: Patient Financial Services Revenue Integrity Patient Billing Office Revenue Cycle Office All patients coded for malnutrition in the previous year using the ICD-10 malnutrition codes. For those patients, you also want to know: Payment source (Medicare, private insurance, Medicaid etc..) Final MS-DRG Which malnutrition code was assigned (ICD-10) If severe E43 were any other MCCs assigned to that patient? If mild E44.1 or moderate E44 were any MCCs or other CCs assigned to that patient? If not included in the data from the hospital, use the CMS table for relative weights for each MS-DRG to determine the RW for that MS-DRG. Be sure to use the current year. Relative Weight Primary Diagnosis Secondary Diagnosis DRG Malnutrition Codes are highlighted 5

6 Patient Account Number Assess Importance of NFPA Academy Malnutrition Resources ICD-10- CM Any Diag Coded ICD-10- Multiplied DRG Sequenc CM Diag ICD-10-CM Diag Discharge Actual Differenc by Base Code e Code Name Date What it would be without Pro/cal malnut weight Actual DRG weight e Rate E43 Unspecified severe pro 1/6/2016 MCC RENAL FAILURE W CC RENAL FAILURE W MCC E43 Unspecified severe pro 1/6/2016 MCC CELLULITIS W/O MCC CELLULITIS W MCC E43 Unspecified severe pro 1/18/2016 MCC INFLAMMATORY BOWEL DISEASE W CC INFLAMMATORY BOWEL DISEASE W MCC E43 Unspecified severe pro 1/19/2016 MCC MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC E43 Unspecified severe pro 1/21/2016 MCC OTHER VASCULAR PROCEDURES W CC OTHER VASCULAR PROCEDURES W MCC E43 Unspecified severe pro 1/26/2016 MCC SIGNS & SYMPTOMS W/O MCC SIGNS & SYMPTOMS W MCC E43 Unspecified severe pro 1/29/2016 MCC MAJOR SMALL & LARGE BOWEL PROCEDURES W CC MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC Sample of partial data collection spreadsheet Cleveland Clinic: Learn to Diagnose Malnutrition Workshop A.S.P.E.N. Malnutrition Toolkit Certificate of Training in Adult Malnutrition (Abbott Nutrition Health Institute) Malnutrition Severity Assessment Dashboard Hospitals are measured on Quality Image from: CMS.gov 6

7 ecqms Infographic source: ecqi Resource Center ecqms Proposed Malnutrition ecqms Completion of a malnutrition screening within 24 hours of admission Completion of a nutrition assessment for patients identified as at-risk for malnutrition within 24 hours of a malnutrition screening Nutrition care plan for patients identified as malnourished after a complete nutrition assessment Appropriate documentation of malnutrition diagnosis ecqi Resource Center What is the Malnutrition Quality Improvement Initiative (MQii)? MQii Objectives Develop malnutrition quality measures that matter Improve malnutrition care with an interdisciplinary care team roadmap (toolkit) Advance tools that can be integrated into EHR systems to improve care quality The MQii Uses a Toolkit to Support Improved Malnutrition Care The Toolkit provides a clear workflow, as well as associated tools and resources, to support quality improvement and best practices in the screening, assessment, and treatment of older adults admitted to the hospital with or at risk of malnutrition. The MQii is focused on older adults (ages 65 and older) given the significant impact malnutrition has on this patient population and the opportunity to improve care among these patients

8 MQii Tools Setting up data collection Setting up data collection Metrics to Track: (if without electronic monitoring) 1. Gather data on your current nutrition screening tool. 2. Keep specific patient population or units separate. 3. Perform random evaluation of screening. 4. Gather information on break in process. Report/Validate the Data $250,000 Facility Bed Size Date Reported Revenue Collected Comments Hospital A months in 2014 $580,000 $200, $1.2 M 2016 $2.1 M $150,000 Hospital B 95 7 months in 2015 $290,000 $100,000 Hospital C $170,000 Hospital D $320,141 $50,000 Hospital E $213,526 Medicare only MCC $ $295,922 Medicare only MCC January February March April May June July August Sept October November December $161, $182, $228, $152, $197, $219, $172, $221, $182, $247, $190, $213, $209, $216, $208, $228, $247, $256, $256, $246, $276, $310, $283, $295, Linear (2016) Linear (2017) $350,000 $300,000 8

9 Tracking and Quantifying Payment $300, Incremental Revenue YTD Tracking and Quantifying Payment $250, $200, $150, $100, $50, $ MONTHS Target Validating & Tracking: Continued Audit denials can occur after the bill is submitted Auditors can claim inadequate documentation for ICD-10 code described at discharge Denial of coding is reported to the facility s coding department Ask that the coders contact you with all malnutrition denials Conduct regular chart audits and evaluate the appropriateness of the malnutrition diagnosis. Check for any diagnosis that may trigger a red flag such as: Kwashiorkor (E40) Marasmus (E41) Marasmic kwashiorkor (E42) Tracking Tracking: Quality Indicators Outcomes Average length of stay for patients receiving malnutrition care since implementation Readmission rate of patients receiving malnutrition care since implementation Percentage of patients diagnosed with Malnutrition following NFPA training Conclusion Outcomes show the true picture! It s imperative to measure outcomes with new interventions to demonstrate the impact. Clinical dietitians can demonstrate their value by demonstrating both patient and financial outcomes. There are many resources to assist you. Take advantage of any technology you have at your disposal. 9

10 References Fontes D Clin Nutr 2014;33: Tappenden K et al. JPEN 2013;37: White J et al. JAND 2012;112: Barker et al. Int J Environ Res Public Health. 2011;8(2): Fry DE et al. Arch Surg. 2010; 145(2): Corkins M et al. JPEN 2014;38: Fingar R et al. 2016; HCUP Statistical Brief #218 Goates S et al. JPEN 2014;38(2):77S-85S References Mogensen K et al. JPEN 2017;00:1-9 Hudson L et al. JPEN 2018;00:1-6 Elia M et al. Clin Nutr 2005;24: Skipper et al. JPEN 2012;36: Phillips W. Support Line 39;3, June, 2017 White J et al. JAND 2012;112: