Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 14, 2019 to October 21, 2019.

You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the billing of DRG 871 with primary diagnosis A41.9 The Plan denied your request. The Plan says the medical records do not support the billing of DRG 871 with primary diagnosis A41.9

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 DRG 871 with primary diagnosis 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. Our reviewer says that the medical records do not support the billing of DRG 871 with primary diagnosis A41.9. Our physician reviewer found the enrollee was accepted in transfer, having presented elsewhere reporting nausea and coffee-ground emesis. Vital signs included a temperature of 98.4F with a pulse of 87/minute, blood pressure of 97/42 and respirations of 12/minute with a pulse oximetry reading of 93% while receiving nasal oxygen at 2L/minute. She was described as being awake and alert. She received intravenous fluids and empiric intravenous antibiotics; nasal oxygen continued at 2L/minute. The white blood cell count was 10.0K/uL with a platelet count of 165K/uL, a hemoglobin of 12.1g/dL and hematocrit of 36.7%. Blood glucose was 114mg/dL. Serum creatinine was 1.59mg/dL with a BUN of 25mg/dL. Total bilirubin was 0.6mg/dL. Lactic acid level was 1.10mmol/L. Chest x-ray revealed a right lung infiltrate. The enrollee was admitted for the management of suspected upper gastrointestinal hemorrhage, pneumonia, volume depletion and demand ischemia. Supplemental oxygen was weaned to room air with pulse oximetry readings in the low 90% range. The serum creatinine declined from 1.59mg/dL on 10/15/2019, 0.75mg/dL, on 10/16/2019, after initial hydration. The creatinine level declined further 0.68mg/dL on 10/19/2019, and was 0.77mg/dL on 10/20/2019, the day prior to discharge. Hypoxemic respiratory failure is characterized by a PaO2 of less than 60mmHg, with a normal or low PaCO2. Acute respiratory failure is characterized by life-threatening derangements in arterial blood gases and acid-base status. There was no arterial blood gas in this case. This enrollee reportedly manifested a room air pulse oximetry reading of 88% at the transferring facility, rising to 95% with 2L/minute of nasal oxygen. She was maintained on nasal oxygen at 2L/minute with pulse oximetry readings in the low 90% range. Once weaned off of supplemental oxygen, her room air pulse oximetry reading was in the low 90% range. The diagnosis code for Acute respiratory failure is not supported for this enrollee who experienced aspiration pneumonitis with mild hypoxia corrected with only low-flow supplemental oxygen. The review has determined that the medical records did not support the billing of DRG 871 with primary diagnosis A41.9: 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 the inpatient hospital services provided from October 14, 2019 to October 21, 2019.