Inpatient Reimbursement

Hospitals receive payment from Medicare, Medicaid and commercial insurers.  Payment is usually determined based on the patients’ admitting diagnosis (bundled payments), not the actual care provided (fee for service).  Diagnoses are identified with codes from the International Classification of Diseases, 10^th Revision (ICD-10).  These codes, called Diagnosis Related Groups (DRG), have associated Relative Weights (RW).  Payment is determined by multiplying the RW of the DRG by the hospital’s base rate.  The base rate for Medicare is predetermined, while the base rate for commercial insurers is negotiated by the hospital. 

Because there are many factors that increase the cost of care for some patients, other codes called Comorbid Conditions or Complications (CCs) or Major Comorbid Conditions or Complications (MCCs) may be assigned to the patient’s stay.  When a CC is applied, it increases the RW of the DRG, which is increased even further by applying an MCC.  Only one CC or MCC needs to be assigned to increase the RW.

There are several CC and MCC codes designated for malnutrition.  A malnutrition diagnosis may not always result in increased payments; if the patient already has another CC or MCC, the addition of a malnutrition code will not further increase reimbursement.  However, in some cases, malnutrition will be the only CC or MCC, thereby resulting in increased payment to the hospital, sometimes thousands of dollars per patient. 

Reimbursement differences can be quantified to estimate both the increase in reimbursement, as well as missed reimbursement for those patients in which the RDN identified malnutrition, but it was not documented by the physician.  Estimated reimbursement and missed payment data can be presented to both administration and medical staff to highlight the value of the RDN in the hospital setting.

Although codes are assigned based on the physician’s documentation only, RDNs can still assist in identifying, documenting and treating malnutrition.

• Ensure the hospital and medical staff adopt evidence-based criteria to define malnutrition

• Educate physicians, nurses and other providers on malnutrition characteristics and the importance of identifying and treating malnutrition

• Use validated malnutrition screening tools

• Ensure RDNs are competent to diagnose malnutrition, including conducting nutrition focused physical exams

• Document malnutrition appropriately by including etiology, detailed signs and symptoms and the treatment plan

• Assist in designing the electronic health record to optimize the nutrition screening process, RDN referrals, RDN malnutrition documentation and physician notification of the RDNs’ findings

• Implement individualized malnutrition treatment plans

• Obtain order writing privileges to facilitate the timely implementation of treatment plans