Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from September 13, 2019 to September 17, 2019.

You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the DRG billed is inappropriate.

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 DRG 0D734DZ. 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 the inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the documentation indicates that the provider assigned 0D734DZ (Dilate of low esophag with intralum dev, perc endo approach) as the principal procedure. Upon review of the documentation provided, 0D734DZ is not supported as the principal procedure. The physician noted that the video endoscope was administered per oral and advanced under direct vision. After the procedure, the endoscope was desufflated and retracted orally. In addition, there was no mention of incision for port access. Further review of the operative/procedure report reveals that the appropriate ICD-10-PCS approach is Via Natural or Artificial Opening Endoscopic, defined as entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure. In accordance with this reference and physician documentation provided, 0D734DZ has been replaced with code 0D738ZZ (Dilation of lower esophagus, endo) as the revised principal procedure. Additionally, the provider assigned R13.14 (Dysphagia, pharyngoesophageal phase) and J69.0 (Pneumonitis due to inhalation of food and vomit) as the principal diagnosis and secondary diagnosis. Upon review of the documentation provided, R13.14 is not supported as the principal diagnosis. The enrollee was admitted due to difficulty of swallowing solid and liquids. It was noted by the physician that the enrollee has aspiration pneumonia and the enrollee was treated with antibiotics. Per the guidelines referenced below, codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related definitive diagnosis has been established. In addition, codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes only when a related definitive diagnosis has not been established (confirmed) by the provider. The documentation supports that dysphagia was a sign/symptom of aspiration pneumonia. In accordance with this reference and physician documentation provided, J69.0 has been sequenced as the revised principal diagnosis. This results in a change in DRG from 326 to DRG 179.

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 September 13, 2019 to September 17, 2019.