ModifiedCentenePolicy CC.PP.145

Payment Policy: Severe Malnutrition

Defines documentation, coding, and retrospective audit requirements for inpatient claims billed with severe malnutrition and how reimbursement adjustments are determined; applies to providers submitting inpatient facility claims to Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyPayment Policy: Severe Malnutrition

Policy CodePolicy CC.PP.145

Change TypeCriteria revisions and coding update

Effective Date

Next Review Date

Key ActionProvide complete physician documentation in the inpatient record to support severe malnutrition diagnosis for retrospective audit and reimbursement validation.

SourceLink

POLICY UPDATE CHANGES

Changed I.A.1.a threshold from BMI 16 kg/m2 to BMI < 18.5 kg/m2.

Updated I.A.5.a and I.B.1.a to >2% weight loss in one week as a criteria option.

Added ICD-10 code E43 (Unspecified severe protein-calorie malnutrition) to the coding table.

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

30 daysclinical validation review timeframe from receipt of records

E43ICD-10 code listed for severe malnutrition

Allproduct types applicable

Tworequired criteria (any two) to meet severe malnutrition coding under I.A

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Retrospectiveaudit approach used for validation

Coverage Criteria for Severe Malnutrition

Documentation-based coverage criteria for severe malnutrition

All of the following must be clearly documented in the inpatient hospital record by the physician or licensed independent practitioner to support a severe malnutrition diagnosis for reimbursement:

Coverage governance and precedence

Coverage and payment determinations are subject to applicable coverage documents, legal/regulatory requirements, and may be overridden by state Medicaid or Medicare determinations where specified.

ALL of the following

Adhere to plan-level coverage documents: coverage and payment determinations and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, policy, contract).
State Medicaid precedence: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with this payment policy, state Medicaid provisions take precedence; refer to the state Medicaid manual for details.
Medicare NCDs/LCDs: For Medicare members/enrollees, review applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) prior to applying this policy's criteria to ensure consistency.
Policy status and limits: This payment policy is a guide to payment and does not constitute a contract, guarantee of payment, or medical advice; Health Plan may change, amend or withdraw this payment policy and the effective date is determined by Health Plan. Providers retain professional judgment and are independent contractors.

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Coding and Clinical Thresholds

ICD-10 Codes - CoveredICD-10Covered

E43	Unspecified severe protein-calorie malnutrition

External coverage referencesmixed

No codes listed

BMI and weight-loss thresholds — adults

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

Acute weight-loss — 1 week> 2% unintended weight loss in one week

Unintended weight-loss — 1 month> 5% unintended weight loss in one month

Unintended weight-loss — 3 to 12 months> 7.5% in three months; > 10% in six months; > 20% in one year

Current weight relative to usual/idealCurrent body weight < 70% of usual body weight or < 70% of ideal body weight (IBW)

Pediatric and neonatal thresholds

Provider Actions, Audits, and Payment Guidance

Documentation Required

Retrospective audit and medical record requests

The Health Plan may perform retrospective audits of inpatient claims identified through paid claims data and a proprietary clinical algorithm to validate severe malnutrition billing. When a potential billing discrepancy is identified the Health Plan will request medical records from the provider to validate the diagnosis and procedure codes billed. Providers must respond to record requests within the timeframe specified in the request. Once records are received, certified professional coders and registered nurses — under the oversight of the Health Plan Medical Director — will clinically validate the documentation to ensure the medical record contains the necessary information, the diagnosis code on the claim matches the medical record, and the diagnosis billed is supported by the clinical information.

Medical record reviews are completed within 30 days from receipt of medical records.
After review the Health Plan will issue an audit determination letter explaining the determination and appeal/dispute instructions.
Explanation of Payment (EOP) reason codes that may be used at the conclusion of review: iA = Deny: Medical records not received per previous request; iB = Pay: DRG payment increase after review; iC = Pay: DRG payment adjustment after review; iE = Deny: DRG inpatient payment denied after review (Observation claim); iF = Pay: Reinstate payment after review.

Definitions

Diagnosis Related Groups (DRG)

DefinitionPatient classification scheme that relates the type of patients a hospital treats (case mix) to the costs incurred by the hospital

Case mix componentsIncludes severity of illness, prognosis, treatment difficulty, need for intervention, and resource intensity

UseDRGs are used to group inpatient cases for reimbursement and resource accounting

Major Complication or Comorbidity (MCC)

DefinitionDiagnosis code(s) used by Medicare to assign individual cases to MS‑DRGs based on severity of illness

PurposeIdentifies major complications or comorbidities that increase case severity for payment classification

Policy Summary

PayerCentene

PolicyPayment Policy: Severe Malnutrition

Policy CodePolicy CC.PP.145

Change TypeCriteria revisions and coding update

Effective Date

Next Review Date

Key ActionProvide complete physician documentation in the inpatient record to support severe malnutrition diagnosis for retrospective audit and reimbursement validation.

SourceLink

On This Page

Pediatric BMI/Z-score criteriaAge < 18 years and > 28 days: BMI‑for‑age, length/height‑for‑age, weight‑for‑height (WHZ) or length Z‑score > 3 standard deviations below median

Mid‑upper arm circumference (MUAC)MUAC < 11.5 cm or > 3 standard deviations below median

Infant/child inadequate weight gainAge ≤ 23 months: gaining < 25% of expected weight (reduced weight gain velocity); Age 2–20 years: unintentional loss ≥ 10% of usual body weight

Neonate age-specific criteriaNeonate (>2 weeks to ≤28 days): decline in weight‑for‑age Z score > 2 SD; weight gain velocity < 25% expected; ≥7 consecutive days intake ≤75% estimated needs; linear growth velocity <25% expected; decline in length‑for‑age Z score >2 SD

Note

General payment determination guidance

Payment determinations are a guide to assistance in making coverage and payment decisions and do not guarantee payment. Claims and payment determinations remain subject to all terms, conditions, exclusions and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance), applicable state and federal law, and plan-level administrative policies and procedures. The Health Plan may change, amend, or withdraw this payment policy at any time and is not providing medical advice or directing clinical practice. Providers are expected to exercise professional medical judgment and are solely responsible for member care.

When state Medicaid provisions conflict with this policy, state Medicaid provisions take precedence for Medicaid members/enrollees.
For Medicare members/enrollees, applicable Medicare NCDs and LCDs must be reviewed and followed where applicable.

RelevanceMCC presence can change MS‑DRG assignment and affect reimbursement under IPPS

MS‑DRG / Inpatient Prospective Payment System

MS‑DRG definitionClassification of diagnoses according to severity for payment under the Inpatient Prospective Payment System (IPPS)

Information usedClassification is based on the hospital‑reported principal diagnosis, up to 24 additional diagnoses, and up to 25 procedures performed during the hospitalization

IPPS payment methodIPPS reimburses inpatient services using predetermined, fixed amounts tied to DRG/MS‑DRG classifications

Health Plan (policy definition)

Meaning in this policy'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 applicable affiliate

RoleHealth Plan provides the payment policy as a guide to payment, subject to plan terms, conditions, exclusions and limitations

AuthorityHealth Plan may change, amend or withdraw this payment policy; effective date is determined by Health Plan

Providers — status and responsibilities

Provider relationshipProviders are independent contractors who exercise independent judgment; Health Plan has no control or right of control over providers

Agency statusProviders are not agents or employees of Health Plan

Clinical responsibilityProviders are solely responsible for medical advice and treatment of members/enrollees