In Kwashiorkor crackdown, CoxHealth to repay $123K

Cox Medical Center Branson has agreed to refund $122,951 in Medicare payments as a result of incorrect medical coding following an audit by the Department of Health and Human Service’s Office of the Inspector General.

According to an inspector general report of the hospital’s audit released last month, a total of $711 million in Medicare claims made nationwide during 2010 and 2011 included a medical code related to diagnoses for Kwashiorkor, a severe form of protein malnutrition. Because the disease generally affects children in tropical and subtropical areas, the influx of Medicare claims prompted the IG’s review of hospitals using the code. So far, auditors have reviewed 18 hospitals across the nation.

At the Branson facility, Cox Medical Center spokeswoman Melinda Honey said the error is connected to software the hospital uses for medical coding and billing. According to the IG’s report, the errors occurred when the facility was still known as Skaggs Regional Medical Center and continued into the first year of the Cox acquisition.

“It has nothing to do with the doctor not knowing what the issue is, it all comes down to billing,” Honey said.

She said Springfield-based CoxHealth’s software asks coders a series of questions and, based on their answers, assigns a code determined by International Classification of Diseases, Ninth Revision, Clinical Modification – a classification system in use since 1979.

Len Piccari, an audit manager for the IG, said other hospital officials cited similar issues with software and the guidelines used in coding diagnoses.

“That seems to be the same issue hospitals have told us about,” Piccari said. “There was a lack of clarity in the guidance that made it seem like you could use the diagnosis for Kwashiorkor to bill for strictly protein malnutrition.”

Piccari said after guidelines were refined in 2009 – with input from such groups as the Centers for Medicare and Medicaid Services, American Hospital Association, World Health Organization and Centers for Disease Control and Prevention – the number of hospitals’ Kwashiorkor claims declined.

The reviews by the IG, he said, are intended to ensure hospitals comply with the clarification.

“Guidance is something we’re still looking at to see whether or not we can determine how this happened and how we can prevent it in the future,” he added.

The code
Payments made to hospitals by CMS are based on predetermined rates, which vary according to the diagnosis code and the associated level of severity.

Cox Medical Center Branson received roughly $1.15 million in Medicare payments between 2010 and 2013 for 112 inpatient claims, which included the Kwashiorkor diagnosis code 260. The IG found none of the patients were diagnosed as having the disease, Piccari said.

Between February and April this year, the IG audited 59 claims at Cox Branson amounting to just over $540,000 in Medicare payments, omitting managed care claims and those under separate review. According to the IG’s report, 21 of the 59 claims were disregarded because correcting the diagnosis code would not have changed the amount of the Medicare payments.

“Some of these patients are very sick and they have a lot of different diagnoses codes that the hospitals have to treat,” Piccari said, adding there can be as many as 15 codes on a single Medicare claim. “For some of them, it didn’t change the payment rate at all, adding the diagnosis code.”

Piccari said the remaining claims using the 260 code were deemed to be in error because they were related to patients with less severe health problems related to malnutrition. Those 38 claims resulted in the amount Cox Branson will refund.

Honey said the health care system is hopeful adoption later this year of new classification standards to medical coding and billing software across the U.S. also will help address the problem.

“We’re really excited about ICD-10, which is the new classification that goes live in October,” she said. “It’s expected to provide a significant increase in the specificity of the reporting to alleviate possible errors like this.”

Hospital response
Piccari said in addition to software patches prompting users to double-check the code assigned to a claim, the biggest response the IG received from reviewed hospitals was implementing additional training for coders.

“If they’re going through the medical records and there is something they are unsure of or something that they are questioning what code to use, they can query the physician over what the physician diagnosed and what the patient had,” Piccari said.

“It does come down to what the physician says. They’re the ones who are determining what the patient has and how it needs to be treated, so the coders have to interpret that.”

CoxHealth spokeswoman Michelle Leroux said the health care system has trained coding staff on the correct procedure for entering the codes to avoid more miscoded Kwashiorkor claims.

“I think what it boils down to is it’s not just software issues,” Leroux said. “It’s kind of like you’ve got a calculator, but if you’re not putting in the right information it’s not going to work.”

Piccari said the IG doesn’t consider the Kwashiorkor miscoding a current issue because of the decreased number of claims in 2014 and 2015. The federal office is still reviewing and auditing hospitals that have used the code since 2009. Total Medicare refunds by the 18 hospitals audited is approaching $3.6 million, according to IG reports.

“We’ll have to see how it works out,” he said, adding there is no current estimate of how many more hospitals or claims might be affected by the coding error. “We’re certainly going to look at the data and analyze it to see how far we want to go.”