Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from January 18, 2020 to January 21, 2020 with the reported principal diagnosis code A1.9.
You asked the Plan to pay for the inpatient services provided from January 18, 2020 to January 21, 2020 with the reported principal diagnosis code A1.9. The Plan denied your request. The Plan says that the secondary diagnosis code N17.0 has been replaced with code N17.9 (Acute kidney failure, unspecified), which has been sequenced as principal diagnosis and code I50.43 has been replaced with code I50.42 (Chronic combined systolic and diastolic hrt fail). This recommendation results in a change from DRG 871 to DRG 683.
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 principal diagnosis code A1.9, miliary tuberculosis. 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 871 for the inpatient services provided from January 18, 2020 to January 21, 2020.
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, an 81-year-old female who was hospitalized from
January 18, 2020 to January 21, 2020. The enrollee presented to the facility for treatment of abdominal pain. The provider cited a creatinine of 1.6 as supportive of sepsis; however, in a patient with chronic kidney disease for which no baseline creatinine is documented the degree of change, if any, is not known and a SOFA score cannot be assigned. It is acknowledged that the enrollee exhibited hypotension; however, this finding, without further evidence of sepsis per Sepsis-3 standards, would not support the coding of this condition. It is acknowledged that ATN was reported in a provider query; however, the diagnosis of ATN is a specific form of kidney injury that denotes significant damage to the proximal tubules. The diagnosis cannot be made from a rise in creatinine alone. The diagnosis is established by characteristic urinary sediment of muddy casts and renal tubular epithelial cells and/or by urinary sodium wasting (a fractional excretion of Na [FENa] > 2%). Review of the documentation acknowledged that the enrollee exhibited a creatinine high of 1.6, indicating evidence of acute kidney injury; however, there was lack of clinical evidence to support the presence of acute kidney failure with tubular necrosis. There was no evidence of muddy casts, granular casts, or renal tubular epithelial cells on urinalysis and urine electrolytes were not obtained. The provider submitted letter cites the presence of hypotension and a BUN/creatinine ratio of less than 20 as supportive of this condition. It is acknowledged that the enrollee was reported with hypotension; however, hypotension is a risk factor for ATN and not evidence of the condition. Additionally, although a BUN/creatinine ratio of less than 20 was reported, this finding, in the absence of further evidence of ATN, would not support the coding of this condition. It was noted that the physician documented acute on chronic systolic and diastolic heart failure in the medical record. However, the weight of the clinical evidence documented in the medical records available for our review failed to support a picture of acute decompensation in this enrollee's state of chronic congestive heart failure. The physical examinations performed throughout the admission did not reveal evidence of acute congestive heart failure such as jugular venous distention, significant pedal edema, extra heart sounds or acute respiratory compromise attributed to this condition. The enrollee denied orthopnea or PND. Additionally, treatment with an intravenous diuretic, as would be expected in a patient with decompensated heart failure, was not provided. There was insufficient clinical evidence and supportive documentation in the records available for review to substantiate the coding of this condition. The review indicates that the principal diagnosis code A1.9, miliary tuberculosis 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 January 18, 2020 to January 21, 2020 with the reported principal diagnosis code A1.9.