Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 7, 2020, to 
March 10, 2020, 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 supported 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 documentation supports an admission for 
gastroenteritis and colitis. From the information that was received, documentation is unclear regarding a 
diagnosis of sepsis. Even though sepsis is noted throughout the medical record, supporting medical record 
documentation was not found. While an elevated white blood cell count and mild tachycardia are noted, 
Systemic Inflammatory Response Syndrome (SIRS) criteria are expected as an appropriate response to 
infection. However, the documentation did not support a manifestation of systemic infection beyond that 
evidenced by SIRS criteria. The enrollee was found to be "extremely orthostatic" and was documented to be in 
no distress and alert and oriented x 3 throughout admission. Per a gastroenterology progress note on March 7th, 
"Syncope most likely due to dehydration". The enrollees leukocytosis quickly resolved with intravenous fluid 
hydration and antibiotics. While the enrollees symptoms warranted consideration of sepsis as a possible 
diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to 
the infection. There was no evidence of a rise in Sequential Organ Failure Assessment (SOFA) of 2 or more 
points that cannot be easily explained by causes other than sepsis. One SOFA point was given for hypotension. 
There is no documentation of hemodynamic instability. There was no evidence of significant physiologic 
instability. 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 March 7, 2020, to March 10, 2020, 
as billed with Diagnosis Related Group (DRG) 872).