Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from July 16, 2021, to August 5, 2021, at the diagnosis related group (DRG) billed.

You asked the Plan to pay for the inpatient services at the DRG billed. You say that acute metabolic encephalopathy is supported by the medical record. The Plan denied your request. The Plan says the secondary diagnosis of G93.41 (metabolic encephalopathy) is not supported in the medical record, resulting in a lower DRG.

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 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 billed. Our reviewer says that the billed secondary diagnosis of G93.41 (metabolic encephalopathy) is not supported in the medical record. Our physician reviewer found the enrollee had a significant past medical history of cerebrovascular accident (CVA), anemia, and hypertension presented to the Emergency Department (ED) via Emergency Medical Services (EMS) with dizziness, syncopal episode and altered mental status that had been present for the previous week. The altered mental status started following a steroid injection in the left knee one week prior to presentation. While ambulating to the bathroom at home, they urinated on themself. Once on the toilet, they sustained a fall to the ground from the toilet and then suffered abnormal shaking. Vital signs on arrival revealed hypertension with blood pressure 196/86, and oxygen saturation 92 % on room air. The physical examination showed slow cognition and difficulty following commands. Confusion was noted, they had trouble word finding, and  was oriented x2 to person and place; but disoriented to time. Computed tomography (CT) head shown left parietal CVA. Labs revealed hypokalemia with potassium 2.7 decreasing to 2.4, BUN 20-21, and ammonia 45. They were admitted to inpatient status for subsequent stroke work-up and management. Orders included aspirin and high intensity statin per stroke protocol, intravenous (IV) fluids, and repletion of potassium, On July 17, 2021, they had significant improvement in mentation. Internal Medicine Progress Notes showed they were communicating properly, aware of surroundings and knew the name of the hospital they were at, alert and oriented x 3 on physical exam. Labs revealed potassium had improved to 3.4. MRI noted acute cortical and subcortical infarction of the left posterior parietal lobe with multiple additional small infarcts in bilateral cerebral hemispheres and left cerebellum. Findings were consistent with central embolic etiology. Aspirin and statin therapy continued, and steroids were initiated. On July 18, 2021, progress notes indicated they were alert without any significant deficits. Internal Medicine Progress Note on July 21, 2021, clarified that Acute metabolic encephalopathy was present on admission (POA) now resolved. Following initial clinical improvement, they suffered another neurological event on July 24, 2021, with new left lower extremity weakness and weak left-hand grip. Repeat CT brain revealed evidence of new acute stroke involving right parietal lobe. Steroid dosage was increased, and they weres transferred once inpatient bed became available. 

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 July 16, 2021, to August 5, 2021, at the diagnosis related group (DRG) billed.