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Claims and Payment Policy #145: Incorrect Billing for Severe Malnutrition: Effective 11/15/20

Dear Provider,

WellCare is implementing the following policy for Incorrect Billing for Severe Malnutrition with an effective date of 11/15/2020.

Summary of Policy:

This policy addresses possible provider billing and coding errors when assigning the ICD-10 CM code of severe malnutrition (Diagnosis codes E40, E41, E42, and E43) as a secondary diagnosis. Historically speaking, severe malnutrition diagnosis codes have been billed by providers without appropriate medical record support when other forms of malnutrition should have been coded and reported.

What does this mean for providers?

In accordance with CMS and ICD-10 CM Coding Guidelines, WellCare may retrospectively audit providers regarding diagnosis assignment of severe malnutrition. WellCare will perform a lookback of claims and medical records for appropriate coding and medical necessity of severe malnutrition codes (E40, E41, E42, and E43) that are submitted as a secondary diagnosis. If the severe malnutrition diagnosis was inappropriately used as a secondary diagnosis, known as comorbidities or complications (CCs) and major comorbidities or complications (MCCs), WellCare will recover the overpayment amount by removing the inappropriate severe malnutrition diagnosis from the DRG payment.

Note: The policy at the link below will provide background and references for this type of severe malnutrition medical record review.

Review the complete policy at www.wellcare.com/providers, select your state, select Claims, then Payment Policy.

We are here to help. If you need further information, please contact your Network Representative.

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