Hospitals Overbilled Medicare $1 Billion by Incorrectly Assigning Severe Malnutrition Diagnosis Codes to Inpatient Hospital Claims

Submitting OIG:

Department of Health & Human Services OIG

Report Description:

Nutritional marasmus (diagnosis code E41) and unspecified severe protein-calorie malnutrition (diagnosis code E43) are two types of severe malnutrition. Previous OIG audits of severe malnutrition found that hospitals had incorrectly billed Medicare by using severe malnutrition diagnosis codes when they should have used codes for other forms of malnutrition or no malnutrition diagnosis code at all. Diagnosis codes E41 and E43 (severe malnutrition diagnosis codes) are each classified as a type of major complication or comorbidity (MCC). Adding MCCs to a Medicare claim can result in a higher Medicare payment.

Date Issued:

Monday, July 13, 2020

Agency Reviewed / Investigated:

Department of Health & Human Services

Submitting OIG-Specific Report Number:

A-03-17-00010

Component, if applicable:

Centers for Medicare & Medicaid Services

Location(s):

Agency-Wide

Type of Report:

Audit

View Document:

Attachment	Size
A-03-17-00010.pdf	1.63 MB

Additional Details Link:

https://oig.hhs.gov/oas/reports/region3/31700010.asp

Recommendation Number	Recommendation Status	Significant Recommendation
269060	Open	Yes
To address the 164 incorrectly billed hospital claims in our sample, we recommend that the Centers for Medicare & Medicaid Services: collect the portion of the $914,128 for the incorrectly billed hospital claims that are within the reopening period.
269061	Open	Yes
To address the 164 incorrectly billed hospital claims in our sample, we recommend that the Centers for Medicare & Medicaid Services: CMS notifies appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation.
269063	Open	Yes
We recommend that the Centers for Medicare & Medicaid Services: review how hospitals are using diagnosis code E41 for nutritional marasmus and diagnosis code E43 for unspecified severe protein-calorie malnutrition and work with hospitals to ensure that they correctly bill Medicare when using severe malnutrition diagnosis codes.

Recommendation Number

Recommendation Status

Significant Recommendation

Additional Details

269060

Open

Yes

To address the 164 incorrectly billed hospital claims in our sample, we recommend that the Centers for Medicare & Medicaid Services: collect the portion of the $914,128 for the incorrectly billed hospital claims that are within the reopening period.

269061

Open

Yes

To address the 164 incorrectly billed hospital claims in our sample, we recommend that the Centers for Medicare & Medicaid Services: CMS notifies appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule, and identify any of those returned overpayments as having been made in accordance with this recommendation.