Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 1, 2021, to 
August 25, 2021, as billed with diagnosis related group (DRG) 574. 
 You asked the Plan to pay for inpatient care billed with DRG 574. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 574 is not 
appropriate as the diagnoses of underweight (R63.6) and body mass index (BMI) of 19.9 or less, adult (Z68.1) 
are not supported in the medical record. The Plan argues that DRG 575 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 574. Our 
reviewer says that the diagnoses of underweight (R63.6) and body mass index (BMI) of 19.9 or less, adult 
(Z68.1) are not supported in the medical record for this inpatient admission. Our physician reviewer found that 
on August 01, 2021, the day of admission, nursing flow sheets documented the enrollees height to have been 
68 inches with a body weight of 170 pounds and a reported BMI of 25.85kg/m2. The Initial Nutrition 
Evaluation note on August 02, 2021 documented the enrollees body weight to have been 170 pounds, with an 
overweight BMI of 25.85kg/m2. An Internal Medicine consultation note on August 02, 2021, documented a 
body weight of 170 pounds and a height of 68 inches. An initial "SWAT" (Supplemental Work and Transition) 
consultation note on August 02, 2021, documented a body weight of 170 pounds and a height of 68 inches. 
Follow-up "SWAT" note on August 04, 2021, documented the same height and body weight measures. On 
August 05, 2021, nursing flow sheets documented a height of 68 inches and a body weight of 111.33 pounds 
(50.5kg), with a reported BMI of 16.93kg/m2. The August 24, 2021, nutrition follow-up note documented the 
enrollees body weight to have been 111 pounds on admission, and to have been 111.33 pounds (50.5kg) on 
August 24, 2021. The hospital flow sheets documents anthropometric measurements twice during the 24-day 
hospital admission: on August 01, 2021, and again on August 05, 2021. The enrollees height was reported as 
having been 68 inches at the time of both measures. The enrollees body weight was reported to have been 170 
pounds on August 01, 2021, and 111.33 pounds on August 05, 2021, four days later. The consulting internist 
and SWAT nurse noted a body weight of 170 pounds, and did not describe evidence of an underweight 
appearance. The SWAT consultation note on August 02, 2021, includes a photograph of the enrollees 
colostomy site and suprapubic catheter. The abdomen, as depicted in the photograph, has the appearance of a 
normal-to-mildly increased degree of subcutaneous fat, and does not have the scaphoid appearance that might 
be expected in an underweight patient. The Initial Nutrition evaluation on August 02, 2021, also documented a 
body weight of 170 pounds. The Nutritionist did not describe evidence of an underweight appearance, 
documenting that the enrollees BMI was overweight. The Nutritionist documented that the patient reported a 
stable weight over the prior year. The Anesthesiologist did not comment on the enrollees weight status. 
Likewise, the operating surgeon did not comment on the enrollees weight status or body habitus. Review of 
the hospital record reflects an error in the body weight documented on August 05, 2021, relative to the body 
weight documented on August 01, 2021. There was no Clinical Documentation Improvement query requesting 
clarification of the disparate body weight measures and disparate BMI reports. There is no clinician comment 
regarding an underweight status until the Discharge summary, where underweight was documented based on 
the erroneous body weight measure of 111.33 pounds with the corresponding erroneous BMI of 16.93kg/m2. 
None of the clinician notes comment on the enrollees body weight or habitus, as would be expected given the 
potential impact on planned surgical reconstruction of an underweight patient with decubitus ulcer. The review 
has determined that the medical records did not support the billing of underweight (R63.6) and body mass 
index (BMI) of 19.9 or less, adult (Z68.1). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 574 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from August 1, 2021, to August 25, 
2021, as billed with diagnosis related group (DRG) 574.