ModifiedArizona Complete HealthPolicy CC.PP.145

Severe Malnutrition Payment Policy

Governs retrospective coding validation and reimbursement for inpatient facility claims billed with a diagnosis of severe malnutrition for Health Plans affiliated with Centene/Arizona Complete Health.

Policy Summary

PayerArizona Complete Health

PolicySevere Malnutrition Payment Policy

Policy CodePolicy CC.PP.145

Change TypeCoding/criteria revision and administrative corrections

Effective Date

Next Review Date

Key ActionHealth Plan will perform retrospective audits of paid claims and request medical records when potential billing errors are identified.

SourceLink

POLICY UPDATE CHANGES

Updated policy number from WC.PP.145 to CC.PP.145 and changed I.A.1.a from 16 kg/m2 to 18.5 kg/m2; changed several weight-loss criteria to > 2% in one week and removed albumin/prealbumin from I.A.

Corrected applicable products from 'Medicare' to 'All.'

References reviewed and updated; instances of 'members' corrected to 'members/enrollees'.

Corrected applicable products from 'Medicare' to 'All.'

30 daysclinical validation review completion timeframe from receipt of medical records

E43ICD-10 code referenced

AllProduct types/applicability after correction

DRG audit

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Retrospective audit type

01/2024Revision/last review date

Severe Malnutrition Coverage Criteria

Severe Malnutrition Documentation Criteria

For reimbursement of inpatient claims for severe malnutrition, ALL of the following criteria must be clearly documented in the inpatient hospital record by the physician or licensed independent practitioner.

Age ≥ 18 additional criteria (two of the following)

Unintended weight loss meeting any of: > 2% in one week; > 5% in one month; > 7.5% in three months; > 10% in six months; > 20% in one year; or current body weight < 70% IBW.
Decreased energy intake: ≤ 75% of estimated energy requirement for ≥ 1 month.
Documented severe muscle wasting or documented severe loss of subcutaneous fat.
Measurable and reduced grip strength.
Documented severe fluid accumulation (edema) due to severe malnutrition.

Neonate-specific criteria

Neonate, age > 2 weeks and ≤ 28 days (one of the following)
- Decline in weight-for-age Z score: decline of > 2 SD.
- Weight gain velocity: < 25% of expected rate of weight gain to maintain growth rate.
- Nutrient intake: ≥ 7 consecutive days of protein/energy intake provides ≤ 75% of estimated needs.
- Linear growth velocity: < 25% of expected rate of linear gain to maintain expected growth rate.
- Decline in length-for-age Z score: decline of > 2 SD.
Neonate, age ≤ 2 weeks

General coverage guidance

High-level coverage and application notes for this payment policy.

This payment policy provides guidance on payment determinations but does not constitute a contract or guarantee of payment. Coverage and payment determinations are subject to the terms, conditions, exclusions, and limitations of the member's plan, as well as applicable state and federal law.

When state Medicaid coverage provisions conflict with this payment policy, state Medicaid manuals and provisions take precedence for Medicaid members/enrollees.

For Medicare members/enrollees, providers should review all applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying the criteria set forth in this payment policy.

Coding and Documentation Thresholds

ICD-10 Codes referencedICD-10Covered

E43	Unspecified severe protein-calorie malnutrition

mixed

No codes listed

Documentation criteria thresholds

Adult BMI thresholdAge ≥ 18 years and BMI < 18.5 kg/m2

Unintended weight loss examples> 2% in one week; > 5% in one month; > 7.5% in three months; > 10% in six months; > 20% in one year

Current weight relative thresholdsCurrent body weight < 70% of usual body weight; current body weight < 70% of ideal body weight (IBW)

Intake and growth velocity thresholds (pediatrics/neonates)Intake ≤ 25% estimated energy/protein need; age ≤ 23 months gaining < 25% of expected weight; neonate intake ≤ 75% estimated needs for ≥7 consecutive days; weight gain or linear growth velocity <25% expected

MUAC and Z-score thresholds (children)Mid-upper arm circumference (MUAC) < 11.5 cm or > 3 SD below median; BMI-/weight-/length-for-age or WHZ > 3 SD below median

Provider Actions and Audit Procedures

Documentation Required

Retrospective Audit and Medical Record Request

The Health Plan may conduct retrospective audits when paid claims data or proprietary algorithms identify potential billing errors. When potential errors are found, the Health Plan will request medical records to validate diagnosis and procedure codes billed on the claim. Once records are received, certified professional coders and registered nurses will clinically validate the documentation to ensure the medical record contains the necessary information, the diagnosis code on the claim matches the diagnosis code in the medical record, and the diagnosis billed is supported by the clinical information in the medical record. Reviews are overseen by the Health Plan Medical Director and will be completed within 30 days of receipt of medical records. After review, the Health Plan will issue an audit determination letter explaining the determination and the provider’s dispute rights. The Explanation of Payment (EOP) will include applicable explanation codes (for example: iA = Deny: medical records not received; iB/iC/iF = Pay/adjustment/reinstate after review; iE = Deny: DRG inpatient payment denied after review).

Clinical validation performed by certified coders and RNs
Audit determination letter with dispute instructions issued to provider
Clinical validation completed within 30 days of receipt of records
EOP will include explanation codes (iA, iB, iC, iE, iF)

Definitions

Diagnosis Related Groups (DRG)

DRG definitionPatient classification scheme that relates the type of patients a hospital treats (case mix) to the costs incurred by the hospital; case mix includes severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity.

Purpose in paymentDRGs are used to classify inpatient services for payment determination under prospective payment systems.

Relation to hospital reportingDRG assignment depends on diagnoses, procedures, and documented clinical information reported by the hospital.

Major Complication or Comorbidity (MCC)

MCC definitionDiagnosis code(s) used by Medicare to assign individual cases to MS-DRGs based on severity of illness.

Effect on payment

Policy Summary

PayerArizona Complete Health

PolicySevere Malnutrition Payment Policy

Policy CodePolicy CC.PP.145

Change TypeCoding/criteria revision and administrative corrections

Effective Date

Next Review Date

Key ActionHealth Plan will perform retrospective audits of paid claims and request medical records when potential billing errors are identified.

SourceLink

On This Page

≥ 7 consecutive days of protein/energy intake provides ≤ 75% of estimated needs.

NCD/LCD requirement

Medicare NCD/LCD review requirementFor Medicare members/enrollees, all applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this payment policy.

CMS referenceRefer to the CMS website at http://www.cms.gov for additional information on NCDs and LCDs.

Scope of reviewReview is required to ensure consistency with Medicare coverage prior to applying the criteria set forth in this payment policy.

Note

General payment and coverage determinations

This payment policy is a guide to payment and a component of the Health Plan’s coverage and payment determinations; it does not guarantee payment. Providers must follow all terms, conditions, exclusions and limitations of the member’s coverage documents and comply with applicable state and federal requirements and plan-level administrative policies and procedures. Providers are expected to exercise professional medical judgment and are solely responsible for the medical care of members/enrollees. Prior to applying the criteria in this payment policy, providers should review any plan-specific administrative policies and verify coverage and payment with the member’s benefit documents.

Coverage/payment determinations subject to member contract terms, state and federal law, and plan administrative policies
This policy does not dictate clinical care — providers retain clinical judgment

Billing Rule

Medicaid precedence and Medicare NCD/LCD review

State Medicaid provisions take precedence where they conflict with this payment policy. Providers should refer to the applicable state Medicaid manual for coverage provisions related to this policy. For Medicare members/enrollees, providers should review all applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) (see CMS website) prior to applying this policy to ensure consistency with Medicare requirements.

State Medicaid manual controls when conflicts exist between this policy and Medicaid provisions
For Medicare members, review applicable NCDs and LCDs at http://www.cms.gov before applying this policy

MCCs increase the severity classification within MS-DRGs, which can affect inpatient payment levels under IPPS.

Source of assignmentAssignment is based on documented additional diagnoses reported by the hospital that meet MCC criteria.

MS-DRGs / IPPS

MS-DRGs definitionMedicare Severity Related Diagnosis Groups (MS-DRGs) classify diagnoses according to severity for payment under the Inpatient Prospective Payment System (IPPS).

IPPS relationIPPS reimburses inpatient services using predetermined fixed amounts based on classification such as MS-DRGs.

Data used for classificationClassification is based on the principal diagnosis, up to 24 additional diagnoses, and up to 25 procedures reported during the hospitalization.

Health Plan

Health Plan definition'Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any affiliate.

Policy roleThis payment policy is a guide to payment and does not constitute a contract or guarantee regarding payment or results.

Provider relationshipProviders are independent contractors and not agents or employees of Health Plan.

Medicaid precedence

Medicaid precedence statementWhen state Medicaid coverage provisions conflict with this payment policy, state Medicaid provisions take precedence; refer to the state Medicaid manual for applicable coverage provisions.

Applicability noteThis precedence applies to Medicaid members/enrollees; providers should follow state Medicaid requirements over this policy when conflicts exist.

Reference guidancePayment and coverage determinations remain subject to plan contract terms and applicable law even where state Medicaid provisions apply.