Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided to the enrollee from June 6, 2020 to June 15, 2020 and billed under DRG code 871 for sepsis.

You asked the Plan to pay for inpatient care provided to the enrollee. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says that the diagnosis code submitted for sepsis is not supported by the records. The Qualified Independent Contractor (QIC) agreed with the Plan. Your office submitted additional medical records to the QIC for review indicating the Plan and the QIC quoted the claim incorrectly.

Our Medical Director looked at the case file and the reopen request. At issue is coverage for the appropriate DRG. The QIC  Physician Reviewer determined that the documentation did not support the DRG for Sepsis. Our physician reviewer found Sepsis is not clinically validated and documentation does not support evidence of organ dysfunction/failure by a dysregulated response to infection. A reopen has been requested. The hospital states that they did not bill with DRG 190. The DRG that was billed was 871 (Septicemia or severe sepsis without MV greater than 96 hours with Major Complication or Comorbidity). The Plan disagreed, and recommended DRG 689 (Kidney and Urinary Tract Infections with Major Complication or Comorbidity). The medical records show the enrollee is a 78-year-old woman with a history of hypertension, who presented to the hospital with weakness. She was admitted to the hospital on June 6, 2020 with diabetic ketoacidosis and a urinary tract infection. Laboratory studies were notable for marked leukocytosis, and hyperglycemia. Cultures were obtained, and IV antibiotics were administered. A computed tomography scan demonstrated bilateral hydronephrosis and a Foley catheter was placed. The enrollee developed hematuria, and continuous bladder irrigation was administered. The Endocrinology Consultation dated June 6, 2020 documents that the enrollee was somewhat lethargic. The Endocrinology Progress Note dated June 10, 2020 documents that the enrollee was still mildly confused and confabulating. The Urology Consultation dated June 12, 2020 documents that the enrollee was somewhat lethargic. The enrollee was still mildly confused on June 13, 2020. The Endocrinology Progress Note dated June 15, 2020 documents gram-negative sepsis.

The Infectious Disease Progress Note dated June 10, 2020 documents a bacteremic UTI with E. coli. Blood and urine cultures were positive for E.coli. The enrollee had documented altered mentation on multiple occasions, consistent with sepsis. Inpatient admission was medically reasonable and necessary for the enrollee in this case, with a DRG of 871 (Septicemia or severe sepsis without MV greater than 96 hours with Major Complication or Comorbidity). 

We looked at our Medical Directors review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we have now decided that the Plan has to pay for inpatient care provided to the enrollee from June 6, 2020 to June 15, 2020 and billed under DRG code 871 for sepsis.