Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from July 6, 2020, through July 13, 2020, as billed.  

You asked the Plan to pay for the inpatient hospital care as billed. You say that the secondary diagnosis is supported by the medical documentation. The Plan denied your request. The Plan says the billed secondary diagnosis is not supported.  

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 the secondary diagnosis code, G93.41, defined as metabolic encephalopathy. 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 secondary diagnosis, G93.41, defined as metabolic encephalopathy. Our physician reviewer found that the review indicates that upon arrival, the triage assessment notes the patient was alert and oriented. It is acknowledged the emergency department provider's exam subsequently noted the patient was confused and argumentative and reevaluation noted waxing and waning confusion; however, the onset of these findings and the patient's baseline status was unclear. The record indicated the patient had been traveling 3 months prior to being at his brother's during the past 2 weeks with confusion noted. Concerns reported by the patient's daughter included questionable dementia. She reported the patient has "spurts of not being coherent, like his thinking is not in the current day, almost like sundowning or dementia," noting he "can tell an old story, but struggles with current day events." The admitting provider's History and Physician Examination noted the patient relayed information regarding recent move, increased diarrhea, and falls, which the daughter confirmed as accurate sequence of events, also stating the patient "has had increased confusion that seems to wax and wane, occasionally he does not recognize people that he knows, and he seems to get confused easily." The time frame for which the waxing and waning confusion has been present is unclear. While subsequent progress notes included confusion and acute encephalopathy, provider exams also included alert and oriented x3 with Neurologic exam noting CN II-XII grossly intact, normal speech, no focal deficits. On July 9 the provider again noted alert and oriented x 3, however stated "Acute encephalopathy, now at baseline." The change to baseline on July 9 was unclear as the provider's exam was unchanged from previous days. The correspondence indicated neurologic checks supported a diagnosis of metabolic encephalopathy, yet the nursing neuro checks from presentation to discharge relayed patient obeys commands, is oriented x 3-4, converses, and has Glasgow Coma Scale score total of 15 with 7/7 assessment noting the patient is forgetful with short term memory loss. The review has determined that the documentation did not support the billed secondary diagnosis.    

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 July 6, 2020, through July 13, 2020, as billed.