Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from November 22, 2019, through November 26, 2019 with the reported diagnosis code E87.1, Hypo-osmolality and hyponatremia.

You asked the Plan to pay for inpatient services provided from November 22, 2019, through
November 26, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia. The Plan denied your request. The Plan says intravenous fluid therapy in the hospitalized patient is considered routine to maintain fluid and electrolyte balance and does not validate the diagnosis of hyponatremia.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with diagnosis code E87.1, hypo-osmolality and hyponatremia We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient services provided from November 22, 2019, through November 26, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia.

Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the enrollee was a then 81-year-old male who presented to the ER on
November 22, 2019 for the evaluation of worsening lower extremity pain. Per the documentation his serum sodium during the hospitalization from November 22, 2019, through November 26, 2019 ranged from 130-138. Hyponatremia is decrease in serum sodium concentration < 136 mEq/L (< 136 mmol/L) caused by an excess of water relative to solute. Common causes include diuretic use, diarrhea, heart failure, liver disease, renal disease, and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Clinical manifestations are primarily neurologic (due to an osmotic shift of water into brain cells causing edema), especially in acute hyponatremia, and include headache, confusion, and stupor; seizures and coma may occur. Diagnosis is by measuring serum sodium. Serum and urine electrolytes and osmolality and assessment of volume status help determine the cause. Treatment involves restricting water intake and promoting water loss, replacing any sodium deficit, and correcting the underlying disorder. In this case the reported hyponatremia was not clinically significant and did not require specific treatment. The review has determined that the diagnosis code E87.1, hypo-osmolality and hyponatremia, was not supported by the medical records.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from November 22, 2019, through November 26, 2019 with the reported diagnosis code E87.1, hypo-osmolality and hyponatremia.