Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from March 9, 2019, through March 13, 2019 with the reported secondary diagnosis, J96.01.

You asked the Plan to pay for the inpatient services provided from March 9, 2019, through March 13, 2019 with the reported secondary diagnosis, J96.01. The Plan denied your request. The Plan says the removal of the diagnosis code and change in DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely on coding guidelines.

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 the secondary diagnosis, J96.01, Acute respiratory failure with hypoxia. 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 DRG 193 for inpatient hospital services provided from March 9, 2019, through March 13, 2019. Our reviewer says that the documentation does not support that the inpatient care is payable as billed.

Our physician reviewer found that the documentation indicates that the enrollee was a then 71-year-old female who was admitted with Influenza A on March 09, 2019. She had a pertinent medical history of chronic obstructive pulmonary disease, reported to be in exacerbation on admission, and tobacco abuse. The review of the documentation acknowledged that the enrollee exhibited an initial oxygen saturation of 100% on room air on admission in addition to 99% on 2 liters of oxygen via high-flow nasal cannula. Although the enrollee exhibited increased work of breathing, significant hypoxia was not reported. Initial oxygen saturation was noted to be 100% on room air which is not indicative of acute respiratory failure or evidence of abnormal gas exchange in a patient with chronic obstructive pulmonary disease. Though the enrollee was provided low flow supplemental oxygen via nasal cannula over this admission, utilization of high flow supplemental oxygen, non-invasive ventilation, or mechanical ventilation was not required as one would expect for a patient with a life-threatening condition of acute respiratory failure. Though acute respiratory failure was documented, there was insufficient clinical evidence in the records available for review to substantiate the coding of this condition. The removal of the diagnosis code and change in DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely on coding guidelines. The review indicates that the secondary diagnosis, J96.01, acute respiratory failure with hypoxia 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 March 9, 2019, through March 13, 2019 with the reported secondary diagnosis, J96.01.