Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from May 10, 2021, to May 
15, 2021, as billed with Diagnosis Related Group (DRG) 478. 
 
You asked the Plan to pay for inpatient care billed with DRG 478. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 478 is not supported as the diagnosis of urinary tract infection, site not specified (N39.0) is not supported in the medical 
record. The Plan argues that DRG 479 is more appropriate in this case, and the medical records better reflect a 
diagnosis of bacteriuria (R82.71). 
 
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. 
 
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 care billed with DRG 478. Our 
reviewer says that the diagnosis of urinary tract infection, site not specified (N39.0) is not supported in the 
medical records for this inpatient admission. Our physician reviewer found that the documentation indicates 
that the enrollee presented to the facility with complaints of left hip pain following a fall. The enrollee's past 
medical history included arthritis, bladder infection, hemorrhoids, hypertension, osteoporosis, and pneumonia. 
Work up revealed a left femur fracture, and the patient underwent an open reduction and internal fixation 
(ORIF) on May 11, 2021. While a diagnosis of urinary tract infection (UTI) was also noted, the clinical 
evidence did not support the condition. To validate the diagnosis of urinary tract infection, the medical record 
is examined for: documentation of an acute episode of local or systemic symptoms typically associated with 
cystitis or pyelonephritis, positive urine culture and appropriate treatment. In the absence of a reliable urine 
culture result, the urinalysis is reviewed for one or more of the following features: positive nitrites, positive 
leukocyte esterase (LE) or greater than 5 white blood cells per high power field (WBC/HPF). While the 
urinalysis was positive and the urine culture was positive with greater than 100,000 cfu/ml of Klebsiella 
pneumoniae, there is no documentation of urinary tract symptoms in the medical record. The progress notes 
indicated that the exam was negative for dysuria and hematuria. In addition, the enrollee had a normal serum 
WBC count throughout the admission and was afebrile. The review has determined that the medical records did 
not support the billing of urinary tract infection, site not specified (N39.0). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 478 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from May 10, 2021, to May 15, 2021, as 
billed with Diagnosis Related Group (DRG) 478.