Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from December 7, 2021, to 
January 6, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient care at the DRG originally billed. You say that procedure code 
0JBR0ZZ (excision of subcutaneous or fascia of the left foot) is supported in the medical record, so the DRG 
should be paid as billed. The Plan denied your request. The Plan says the billed DRG is not supported because 
the procedure code billed for the debridement service was not accurate. The procedure code billed was 
0JBR0ZZ which is defined as excision of subcutaneous or fascia of the left foot. However, based on the 
medical records, the correct procedure should have been billed as 0HBNXZZ, which is defined as Excision of 
Left Foot Skin, external approach. This is because based on the clinical records, the wound debridement 
performed does not support that a debridement of subcutaneous tissues took place. Rather, only a thin layer of 
slough was removed from the wound center and a callus of the peri-wound was excised. 
 
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 procedure code 0JBR0ZZ (excision of 
subcutaneous or fascia of the left foot). 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 care at the DRG originally billed. Our reviewer says that procedure code 0JBR0ZZ is not supported in 
the medical record. Our physician reviewer found that the enrollee was a then, 70-year-old with a history of 
diabetes, diabetic foot ulcers, trans-metatarsal amputation of the left foot, below-knee amputation of right lower 
extremity, hypertension, and coronary artery disease. 
 
On October 29, 2021, he developed complaints of his left foot and leg in relation to a wound noted on the left 
plantar residual foot. He was seen for outpatient wound care where wound care and debridements were 
performed. On November 24, 2021, imaging of his left foot was performed and confirmed that the enrollee had 
left foot osteomyelitis.  
 
On December 7, 2021, the Plan approved a prior authorization for him to be admitted to a non-contracted Long 
Term Acute Care Hospital (LTACH). The enrollee was admitted for IV antibiotics to treat left foot 
osteomyelitis. On December 13, 2021, a skin debridement of his left foot plantar wound was performed by the 
LTACH's wound care nurse. The nurse's notes documented that the debridement involved excision of a callus 
to the peri-wound and excision of a thin layer of slough on the wound bed, exposing red and pink viable tissue. 
There was no anesthesia given prior to the procedure nor was there a surgeon or practitioner present. There was 
no further documentation of subsequent debridements submitted, and the enrollee was discharged from 
LTACH on January 6, 2022. You billed with a surgical DRG of DRG 622 {Skin Graf ts and Wound 
Debridement for Endocrine, Nutritional, and Metabolic Disorders with Major Complication or Comorbidity 
(MCC)}, and included procedure code, 0JBR0ZZ (Excision of left foot subcutaneous/fascia, open approach). 
The Plan changed the DRG to 637 (Diabetes with MCC). The debridement performed on December 13, 2021, 
was not a debridement of subcutaneous tissue. The procedure was a skin debridement, best coded by 
0HBNXZZ (Excision of Left Foot Skin, External Approach). The review has determined that that 0JBR0ZZ is 
not an accurate procedure code for the debridement performed on December 13, 2021. According to the 
International Classification of Diseases, 10th Revision, Procedure Coding System, 0JBR0ZZ is applicable to 
excision of subcutaneous or fascia of the left foot. Based on the clinical submitted for review, the wound 
debridement performed by the wound care nurse did not support that a debridement of subcutaneous tissue took 
place. It is noted that a thin layer of slough was removed from the wound center, and a callus of the peri-wound 
was excised. However, a surgical debridement of the subcutaneous tissue was not done. Only the epidermal and 
dermal layer of the wound is debrided. The Plan's downgraded code of 0HBNXZZ is appropriate.  
 
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 care provided from December 7, 2021, to January 6, 2022, at the Diagnosis Related 
Group (DRG) originally billed.