Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 20, 2021, 
to November 26, 2021, 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 these 
services were medically necessary and are supported in the record. The Plan denied your request. The Plan says 
DRG 871 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the 
medical record. The Plan argues that DRG 193 is more appropriate in this case. 
 
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 sepsis, unspecified organism (A41.9). 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 diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found that the records note that the enrollee had a 
normal temperature with a respiratory rate of 26 and blood pressure of 140/81. Blood culture results were not 
noted in the record and no Glasgow coma scores were noted. The enrollees mental status was noted as alert 
and oriented to self, not place or time. The enrollees baseline mental status is unclear. 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. 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. Multiple organ dysfunction syndrome (MODS) is characterized by progressive organ 
dysfunction in a severely ill patient, with failure to maintain homeostasis without intervention. It is the end 
stage in infectious conditions (sepsis, septic shock) and noninfectious conditions (e.g., SIRS due to 
pancreatitis). In this case there was no clinical or laboratory evidence of sepsis. The review has determined that 
the medical records did not support the billing of sepsis, unspecified organism (A41.9).  
 
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 November 20, 2021, to November 26, 2021, at the Diagnosis 
Related Group (DRG) originally billed.