Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from April 24, 2021, to 
April 27, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that this Diagnosis Related Group (DRG) 
was billed correctly. The Plan denied your request. The Plan says the billed DRG was not supported because 
the principal diagnosis of A41.9 (sepsis, unspecified organism) is not supported in the medical records. The 
medical record does not support the condition treated as consistent with systemic infectious process. 
 
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 (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 hospital services. Our 
reviewer says that the diagnosis of A41.9 (sepsis, unspecified organism) is not supported in the medical 
records. Our physician reviewer found the documentation from the medical record supported a 3-day admission 
for further evaluation and treatment of pneumonia. The patient had a history of cancer, hypertension, diabetes 
mellitus, and multiple myeloma, and arrived at the hospital with complaints of shortness of breath, fever, and 
confusion while at dialysis. The patient also has a history of end-stage renal disease for which she is on 
dialysis. The patient was brought from dialysis treatment altered and was unable to provide any history. The 
patient was reportedly not confused at baseline. The hospital physician documented in the patient's physical 
exam that the patient was lethargic but arousable. Further doctor consults documented that the patient was not 
feeling well before his dialysis and wanted to cancel, but he went and was noted have a fever up to 104 with 
some confusion. The patient was diagnosed with probable delirium from the fever with renal failure on 
dialysis, and possible pneumonia. A chest x-ray revealed diffuse bilateral lung haziness, differential includes 
pulmonary edema, acute respiratory distress syndrome, or diffuse pneumonia. The records also documented 
patient's mental status as alert and oriented to person, place, and time. The hospital physician documented 
diagnoses of sepsis, acute kidney failure, multiple myeloma, and pneumonia of both lungs due to infectious 
organism, unspecified part of lung. Even though sepsis is documented, supporting medical record 
documentation was not found within the record.  
 
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 April 24, 2021, to April 27, 2021.