Hospital receives more than $300,000 in overpayments for malnutrition claims

Cornerstone Hospital of Bossier City, Louisiana, incorrectly billed Medicare for all claims with a diagnosis of kwashiorkor and received $321,971 in overpayments during a five-year period, according a March report released by the Office of Inspector General (OIG).

Kwashiorkor is a type of severe protein malnutrition that affects children in subtropical or tropical regions during food shortages. Although cases in the U.S. are rare, in 2010 and 2011 Medicare paid hospitals $711 million for claims with a diagnosis code for kwashiorkor. The ICD-9-CM code for kwashiorkor was 260 and due to the severity of the condition triggered a higher DRG payment. The OIG is conducting a review of hospitals that submitted claims for kwashiorkor to determine if they complied with Medicare billing regulations.

Cornerstone Hospital received $5,619,862 for claims with ICD-9-CM code 260 from 2010-2014, according to CMS. The OIG’s auditors looked at 73 of the 189 claims containing the code the hospital billed Medicare for during that time and found that none of the audited claims complied with Medicare billing regulations. The hospital used code 260 even though documentation indicated patients suffered from other forms of malnutrition, according to the report. On 25 of the claims, using the correct diagnosis code would not have changed the Medicare payment; however, on 48 of the claims the error triggered overpayments totaling $321,971.

The OIG recommends that Cornerstone Hospital refund the total amount of overpayments and strengthen internal measures to ensure compliance with Medicare billing regulations.

Cornerstone Hospital contends that although documentation does not support a diagnosis of kwashiorkor, in all cases the medical record shows some form of protein malnutrition. It believed that diagnosis code 260 was appropriate to report for any form of severe protein malnutrition, as the ICD-9-CM Index of Diseases classifies any protein deficiency or malnutrition to code 260. However, the American Hospital Association’s Coding Clinic for ICD-9-CM, Third Quarter 2009, p. 6, clarifies that code 260 should only be used if the provider specifically documents kwashiorkor, but not other types of protein malnutrition.