Dear Provider,
Thank you for your continued partnership with Wellcare. As you know, we continually review and update our payment and utilization policies to ensure they are designed to comply with industry standards while delivering the best patient experience to our members.We are writing today to inform you of revisions to an existing policy that Wellcare will implement for dates of service beginning September 1, 2026. The posted policy includes a revision log explaining the updates that occurred during the annual review.
| Policy Number | Policy Name | Policy Description | Lines of Business |
|---|---|---|---|
| CP.PP.145 | Malnutrition |
Acute care hospitalizations for malnutrition require the most appropriate and specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or licensed independent practitioner. The cost difference between a Diagnosis Related Group (DRG) billed with malnutrition as a major complication or comorbidity (MCC) and a DRG billed without malnutrition as an MCC will be denied reimbursement unless the documentation requirements described in this policy are met. The purpose of this policy is to support a retrospective review of inpatient claims billed with a diagnosis of malnutrition. |
Medicare |
Changes to Reviews Include
- Updated Criteria I to include non-severe (moderate) malnutrition diagnosis criteria guidelines and treatment.
- Added Criteria II to include severe malnutrition diagnosis criteria guidelines and treatment.
- Reviewed coding and descriptions.
- Added ICD-10 codes E44.0 and E44.1.
Thank you for your continued participation and cooperation in our ongoing efforts to provide quality health care to our members. We look forward to helping you provide the highest quality care for our members.
