Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from June 6, 2020, through June 8, 2020, and billed with a principal diagnosis code of J96.21.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the inpatient hospital care as billed. The Plan denied your request. The Plan says there are more appropriate diagnosis codes that should have been billed for these rendered services.  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, J96.21, defined as acute and chronic respiratory failure with hypoxia. 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 provided does not support the inpatient hospital care billed with a principal diagnosis code of J96.21, defined as acute and chronic respiratory failure with hypoxia. Our physician reviewer found that the case involved a then 55-year-old female, with a history of coronary artery disease, congestive heart failure, hypertension, diabetes mellitus, stage IV-V chronic kidney disease, and oxygen-dependent chronic obstructive pulmonary disease (2L/minute of nasal oxygen at baseline) with chronic hypoxic respiratory failure, who was accepted in transfer for ongoing evaluation and management of possible pulmonary embolism, having initially presented elsewhere reporting dyspnea at rest. While the patient reported utilizing home oxygen daily, she also reported being able to tolerate breathing room air at rest without dyspnea. This patient had a history of oxygen-dependent chronic obstructive pulmonary disease. Physician notes documented use at 2L/minute; nursing flow sheets documented use at up to 3L/minute. The Hospital appeal letter argues that since the patient reported being able to tolerate room air at rest, and presented with dyspnea at rest, she therefore exhibited evidence of acute on chronic respiratory failure. However, this argument conflates hypoxia with dyspnea. Notwithstanding the patient's report of being able to sit without supplemental oxygen without experiencing dyspnea, there is no indication as to her baseline at rest room air pulse oximetry or oxygen level. Dyspnea can be present in the absence of hypoxia. This patient required supplemental oxygen at 2L-to- 3L/minute during her daily routine; it is likely that her baseline room air oxygen level is abnormal, if not below 60mmHg, while at rest. While presenting to the outside facility with dyspnea and a reported room air PaO2 of less than 57mmHg, at the time of arrival to the admitting facility, she exhibited a pulse oximetry reading of 93% while receiving baseline supplemental oxygen at 2L/minute. The arterial blood gas on admission revealed a PaO2 of 76mmHg with an oxygen saturation of 94%, and findings consistent with metabolic rather than respiratory acidosis. The patient was described as being in no acute respiratory distress, with non-labored respirations. As this patient, with baseline chronic respiratory failure, did not exhibit a material change oxygenation from baseline, with a baseline line status that included continuous use of supplemental oxygen for routine daily function, the hospital record does not support reporting the diagnosis code for acute and chronic respiratory failure with hypoxia  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 June 6, 2020, through June 8, 2020, and billed with a principal diagnosis code of J96.21.