Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 12, 2021, to June 
16, 2021, as billed with Diagnosis Related Group (DRG) 872. 
 
 
 You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not 
appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 392 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.  
 
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 872. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found that the enrollee presented to the facility with a chief 
complaint of abdominal pain and fever. Emergency department notes stated the enrollee had abdominal pain 
and a fever prior to arrival, however upon presentation the enrollee was afebrile and was described to be 
"normal" in appearance. History and physical notes stated the enrollee was "afebrile...not in any distress...no 
focal neurological deficit." The history states the enrollee was to be admitted for further management of colitis. 
The enrollee was described to have chronic kidney disease stage 3, and while the initial creatinine was 1.4, no 
baseline was stated related to the chronic kidney disease, and it is unclear in significance without provider 
clarification. While the provider stated sepsis, the medical record data was incomplete. The diagnostic 
information indicates the enrollee maintained platelet and total bilirubin levels within normal limits and this 
was documented by the provider. The enrollee was documented to be alert and oriented in the provider 
assessments without documentation of infection induced mental changes. The enrollees oxygen saturation was 
greater than 95% upon presentation without documentation of respiratory insufficiency related to infection. The 
vital signs included mean arterial blood pressures were, "normotensive" as was stated in the correspondence, 
and no provider support of hemodynamic instability or compromise was found. 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 that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from June 12, 2021, to June 16, 2021, as 
billed with Diagnosis Related Group (DRG) 872.