Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from December 6, 2020, 
through December 11, 2020, billed with principal diagnosis code of A41.9 and secondary diagnosis code J18.9. 
 You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient care has been 
billed appropriately. The Plan denied your request. The Plan says the primary and secondary diagnosis codes 
are not supported in the medical documentation. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism and the secondary diagnosis code, J18.9, defined as pneumonia, 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 hospital care as billed. Our 
reviewer says that the documentation does not support the billed principal and secondary diagnosis codes. Our 
physician reviewer found that the review indicates that the enrollee was a then, 75-year-old female with a 
history of Diabetes mellitus type II with long term current use of insulin, diverticulosis of colon, 
gastroesophageal reflux disease, hyperlipidemia, hypertension, macroalbuminuric diabetic nephropathy, 
obesity, osteopenia, and severe obstructive sleep apnea. The patient presented to the emergency department 
after found to be vomiting, with oxygen saturation noted to be in the low 80s per emergency medicine staff. 
The patient reports feeling short of breath as well as general weakness and increased urination. Review of 
symptoms reviews positive for fatigue, shortness of breath, leg swelling, frequency, and rash. Per provider 
documentation: "There is question of pneumonia, particularly aspiration, for which she was initiated on 
antibiotic therapy. She was actually septic in appearance with a fever, leukocytosis, tachycardia, and her source 
being her respiratory status. She initially had an elevated lactic acid. This has resolved. She is on oxygen 
therapy, likely a combination of pneumonia with probable obesity hypoventilation syndrome. Lasix daily and 
oral. Will need motivation as she has been noncompliant with measures here. Her urine is showing E. coli, 
likely contributing to her acute illness, which will be covered by Amoxicillin." Per emergency department 
notes, "I did turn the patient's oxygen off and when she was at rest in the bed she maintained 02 sats above 90% 
The nursing staff noted that if she got up or made any efforts to urinate even in the bedpan, she did drop her 
sats into the 80s again." Even though sepsis is documented, supporting medical record documentation was not 
found within the record. The review has determined that the documentation did not support the billed principal 
diagnosis code A41.9, defined as sepsis, unspecified organism and billed secondary diagnosis code J18.9, 
defined as pneumonia, unspecified organism.  
 
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 care provided from December 6, 2020, through December 11, 2020, billed with 
principal diagnosis code of A41.9 and secondary diagnosis code J18.9.