Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from August 4, 2020, through
August 10, 2020 with the reported secondary diagnosis G93.41, Metabolic encephalopathy.
You asked the Plan to pay for inpatient services provided from August 4, 2020, through August 10, 2020 with
the reported secondary diagnosis G93.41, Metabolic encephalopathy. The Plan denied your request. The Plan
says from the information that was received; the documentation was unclear regarding a diagnosis of Metabolic
encephalopathy. Even though Metabolic encephalopathy is documented as a diagnosis on the history and
physical examination (H&P), progress notes and discharge summary, supporting medical record documentation
was not found within the 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 the secondary diagnosis 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 inpatient services with the
reported secondary diagnosis G93.41, Metabolic encephalopathy. Our reviewer says that the documentation
does not support that the inpatient care is payable as billed. Our physician reviewer found that the review
indicates that the documentation supported an admission for collapsed vertebra, not elsewhere classified,
thoracic region, initial encounter for fracture. The documentation was unclear regarding a diagnosis of
Metabolic encephalopathy. Even though Metabolic encephalopathy is documented as a diagnosis on the H&P,
progress notes and discharge summary, supporting medical record documentation was not found within the
record. Hospital correspondence maintained that encephalopathy was evidenced by the enrollee's altered
mental status (AMS), confusion, and by the performance of a computed tomography (CT) of the head. The
enrollee presented with back pain and AMS. A history of chronic obstructive pulmonary disease (COPD) was
documented. On physical exam the enrollee was noted as alert and oriented to person, place, and time. The CT
of head showed no acute intracranial process. The physician noted "metabolic encephalopathy - possibly
baseline dementia exacerbated by pain/hyponatremia." On consultation date August 5, 2020, the physician
noted "Her granddaughter describes cognitive impairment likely dementia, although she had not had formal
neurologic testing." The enrollee was described as alert and oriented to person, time, and place. During the
hospitalization the enrollee was documented to be alert and oriented to person, time, and place. To support a
diagnosis of encephalopathy submitted documentation must demonstrate that there was a change in mental
status beyond baseline that persisted beyond treatment in the emergency department. While the enrollee's
presentation warranted consideration of metabolic encephalopathy there was no documentation to support a
change in mental status beyond the enrollee's baseline mental status. The review has determined that the
secondary diagnosis, G93.41, Metabolic encephalopathy was not supported by the medical records
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 services provided from August 4, 2020, through August 10, 2020 with the reported secondary
diagnosis G93.41, Metabolic encephalopathy.