Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 21, 2021, 
to July 27, 2021, at the diagnosis related group (DRG) billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG billed. You say that these services 
should be paid at the DRG billed. The Plan denied your request. The Plan says the secondary diagnosis of 
E87.1 (Hypo-osmolality and hyponatremia) is not supposed in 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 code of E87.1 (hypo-
osmolality and hyponatremia). 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 at the DRG billed. Our reviewer says that the secondary diagnosis code of E87.1 (hypo-
osmolality and hyponatremia) was not supported in the medical record. Our physician reviewer found the 
enrollee was a then 73-year-old female who presented to the emergency room for evaluation of abdominal pain, 
nausea, and vomiting. The patient had a past medical history of hyperlipidemia, anxiety, and cataract. The 
patient was diagnosed with disorder of the gallbladder and was admitted for further care. Vital signs were as 
follows: blood pressure 202/77, pulse 57, respiratory rate 18, Total bilirubin 0.2, Sodium 142, BUN 16, 
Creatinine 0.7, Lipase 58, WBC 9.0, and platelet count 411. Computed tomography (CT) revealed a distended 
gallbladder. The history and physical noted that the patient was well-developed, in no acute distress, lungs were 
clear to auscultation bilaterally, and neuro status was alert and oriented x3. The patient was diagnosed with 
acalculous cholecystitis and underwent a laparoscopic cholecystectomy. Progress notes noted the patient had a 
Sodium of 135 on July 23, 2021, with a physician lab interpretation of hyponatremia. The discharge summary 
included the diagnoses of cholecystitis, dyslipidemia, and elevated blood pressure reading. The physician 
documented "CT revealed distended gallbladder and there was non-visualization of the gallbladder seen on 
HIDA scan compatible with cystic duct obstruction. General Surgery was therefore consulted and a lap. chole 
was performed, revealing a necrotic GB. She was covered with empiric Abx during her stay. Post-op recovery 
has been unremarkable. She is stable for discharge home". While it was acknowledged that the physician 
documented the diagnosis of hyponatremia, the medical record documentation did not sufficiently support this 
condition as being present at the time.  
 
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 July 21, 2021, to July 27, 2021, at the diagnosis related group 
(DRG) billed.