Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided form July 3, 2021, to 
July 10, 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 this DRG was 
billed correctly. The Plan denied your request. The Plan says the secondary diagnosis of J96.20 (acute and 
chronic respiratory failure, unspecified whether with hypoxia or hypercapnia) is not supported in the medical 
records, 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 secondary diagnosis of J96.20 (acute and chronic 
respiratory failure, unspecified whether with hypoxia or hypercapnia). 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 
secondary diagnosis of J96.20 (acute and chronic respiratory failure, unspecified whether with hypoxia or 
hypercapnia) is not supported in the medical records. Our physician reviewer found that the medical 
documentation supported an admission for chronic obstructive pulmonary disease (COPD) with acute lower 
respiratory infection. From the information that was received, the documentation was inconsistent/unclear 
regarding a diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or 
hypercapnia. Even though acute and chronic respiratory failure, unspecified whether with hypoxia or 
hypercapnia is reported, supporting medical record documentation was not found within the record. 
The patient has a medical history of continuous positive airway pressure (CPAP) use as needed, asthma, 
eosinophilic asthma, former smoker, and COPD.  They presented to the emergency room (ER) with shortness 
of bread and cough. Per ER provider note, the patient was not in Acute Distress.  The admitting diagnosis was 
acute exacerbation of chronic obstructive airways disease. Per history and physical impression, the patient had 
"shortness of breath-asthma/COPD exacerbation". There was no evidence of blood gases done to support 
arterial blood gas (ABG) pH less than 7.35 or venous blood gas (VBG) pH less than 7.30 with a PaCO2 greater 
than 45 (ABG) or PCO2 greater than 50 (VBG). The patient did not require treatment consistent with acute 
respiratory failure such as high flow oxygen administration, provision of BiPAP (beyond home use), and/or use 
of mechanical ventilation. Treatment was not consistent with acute respiratory failure.  
 
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 form July 3, 2021, to July 10, 2021, at the Diagnosis Related Group 
(DRG) originally billed.