Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 17, 2022, to 
February 26, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical record support the diagnosis billed. The Plan denied your request. The Plan says the diagnosis code 
billed for these inpatient hospital services is not supported. 
 
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, A41.9, defined as sepsis, 
unspecified organism. 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 hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support the services 
as billed with principal diagnosis code A41.9, defined as sepsis, unspecified organism. Our physician reviewer 
found that the review indicates that the enrollee was a 51-year-old male who presented to the facility with the 
chief complaint of 4 days of fevers, chills, body aches, chest pain and shortness of breath. Medical history 
included congestive heart failure, a current everyday smoker and hypertension. Initial vital signs were 
acknowledged to reflect a temp of 100.6, pulse of 112, resp rate of 34 and blood pressure of 160/103. 
Computed tomography shows bilateral lower lobe and right middle lobe infiltrates concerning for pneumonia.  
 
Per Medscape Internal Medicine, sepsis is a life-threatening syndrome usually caused by bacterial infection. 
Sepsis is a response of the body's immune system that results in organ dysfunction or failure. The systemic 
inflammatory response syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure 
Assessment (qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in patients with 
suspected or documented infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, 
systolic blood pressure of 100 mm Hg or less, and altered level of consciousness.  For completeness, severe 
sepsis is defined as sepsis complicated by organ dysfunction. 
 
In this case there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation did not support the billed principal diagnosis code A41.9, defined as sepsis, unspecified 
organism.  
 
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 inpatient hospital services provided on February 17, 2022, to February 26, 2022, at the Diagnosis Related 
Group (DRG) originally billed.