Q&A: Malnutrition denials

Q: Does anyone have experience with denials based on the Global Leadership Initiative on Malnutrition (GLIM) versus the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria?

Response #1: First, as to criteria, it should be made clear to the payer that it is the facility, not the payer, that will set the criteria used to diagnose the condition. This seems straightforward but it will mean your institution will need to have diagnostic criteria that your registered dieticians (RD) and providers have agreed upon. Providers can, of course, make their own diagnosis based on their clinical judgement, but having RD and provider buy-in will help to ensure diagnostic uniformity.

The creation of an RD documentation template containing all the requisite malnutrition criteria is also very useful as it will ensure that the RD’s assessment is consistently captured, and that missing data points will be minimized when formulating an appeal. This also allows for dot phrases or other auto capture of documentation for the providers, ensuring that the diagnosis of malnutrition is not just captured in the RD note.

I would also recommend coder, CDI, provider, and RD collaboration during this process, so that everyone understands what the agreed upon criteria for malnutrition is, the documentation required to support it for coding, and when a clinical validation query might be needed.

Response #2: We receive malnutrition denials based on GLIM versus ASPEN criteria and the process we follow is to review the criteria the auditor uses against the details of the case to evaluate if/how the case may be supported in the appeal. Even though our system follows one type of criteria, sometimes the case meets both. Our team then evaluates if the case meets the auditor’s criteria. As the appeal is formulated, other aspects of the case are then used for further support as needed.

Response #3: Our RDs use the ASPEN guidelines, while the gastrointestinal nutrition team uses the GLIM criteria. Depending on the circumstances in the chart, we may or may not clinically validate using GLIM or ASPEN and respond to denials accordingly. We ask the CDI specialists to ensure that when they introduce malnutrition into the medical record, there is a strong case for treatment based on the OIG’s recommendations. If RDs or providers establish a diagnosis without a query, we will proceed with the denial process as long as we can clinically validate using GLIM or ASPEN.

The denial companies often reference the Coding Clinic from fourth quarter 2016, which they tend to misrepresent. They frequently misapply clinical criteria to fit their narrative. In our responses to these denials, we point out their incorrect application of the Coding Clinic. Additionally, denial companies claim that payers require specific criteria to be used. We counter this by citing the Coding Clinic, which states that a physician can use any criteria to establish a diagnosis. To the best of our knowledge, we are not under contract with the payer to use any specific criteria for clinical validation or diagnosis establishment; if we are, the insurance companies need to provide that contract.

While we will still appeal the first and second time, if we feel strongly about a case, we will not invest time in writing extensive determination letter responses. We have found that, in many instances, regardless of the information presented, they still deny the case, likely hoping to win administratively through paperwork.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and was originally published in the CDI Leadership Insider, a monthly newsletter exclusive to Council members. For the purposes of this article, all Council member answers have been deidentified.