Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from March 21, 2021, to 
March 25, 2021, at the diagnosis related group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed. You say that this diagnosis is 
supported and the claim should be paid at the DRG billed. The Plan denied your request. The Plan says the 
secondary diagnosis of G93.41 (metabolic encephalopathy) is not supported i the medical record. 
 
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 secondary diagnosis of G93.41 (metabolic 
encephalopathy). 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 services at 
the DRG originally billed. Our reviewer says that the diagnosis of G93.41 (metabolic encephalopathy) is not 
supported in the medical record. Our physician reviewer found the documentation supported an admission for 
hypokalemia. Even though encephalopathy is documented in the progress notes, supporting medical record 
documentation was not found within the record. To support a diagnosis of acute encephalopathy, 
documentation must support a change in mental status which is beyond baseline and supported by neurological 
examination findings documented by licensed provider corroboration. This requires clear documentation of the 
member's baseline and should be supported by the provider. The neurological exam must be consistent with a 
diagnosis of encephalopathy and should show improvement with treatment. The patient presented with a chief 
complaint of syncopal episodes. Documentation in the history and physical stated "patient has been having 
confusion since discharge of getting into the wrong car" as reported by family to be occurring at home. 
However, during this admission, there was no clinical evidence supporting a change in behavior beyond the 
patients baseline mental status. Patient remained alert and oriented X 4 with no evidence of neurological 
deficits. The emergency room physical exam documentation states "Neurological: General: No focal deficit 
present. Mental Status: He is alert and oriented to person, place, and time. Deep Tendon Reflexes: Reflexes are 
normal and symmetric. Psychiatric: Behavior: Behavior normal. Thought Content: Thought content normal. 
Judgment: Judgment normal. Syncope documented "Likely related to volume depletion".  
 
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 from March 21, 2021, to March 25, 2021, at the diagnosis related group 
(DRG) originally billed.