Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 27, 
2021, to September 1, 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 the principal 
diagnosis of A41.9 (sepsis, unspecified organism) was supported in the medical record. The Plan denied your 
request. The Plan says the principal diagnosis of A41.9 (sepsis, unspecified organism) is not supported in the 
medical record, so a DRG downgrade was appropriate. 
 
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 a principal diagnosis of A41.9 (sepsis, unspecified 
organism). 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 principal diagnosis of A41.9 (sepsis, unspecified organism) is not 
supported in the medical record. Our physician reviewer found the patient presented with chief complaint of 
weakness, nausea, fever (subjective), and intermittent shortness of breath. Leukocytosis and elevated heart rate 
were documented. Systematic Inflammatory Response Syndrome (SIRS) criteria are expected as an appropriate 
response to infection, however, SIRS criteria alone lack specificity as the same clinical signs, symptoms and 
laboratory data seen in patients with sepsis are also present in populations of critically ill patients with other 
proinflammatory conditions. The documentation did not support a manifestation of systemic infection beyond 
that evidenced by SIRS criteria. Patient remained hemodynamically stable throughout admission with no 
documentation supporting a dysregulated host response to infection. Significance of values must be 
documented by the physician post initial IV fluid resuscitation due to infection and not due to another 
underlying condition, be altered from patient's baseline values, and should be recorded within a 24-hour period 
of each other. Though a diagnosis of sepsis was noted during the stay, laboratory data reflected the patient was 
without clear signs of. systemic response and there did not appear to be evidence of significant 
thrombocytopenia, hepatic or renal dysfunction. The patient remained alert and oriented X 3 with a Glasgow 
Coma Score of 15. No documentation of mean arterial pressure below 70, hypoxia or urine output less than 500 
ml/day was present.  
 
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 August 27, 2021, to September 1, 2021, at the Diagnosis 
Related Group (DRG) originally billed.