Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from November 11, 
2020, to November 14, 2020, 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 the medical 
records support these diagnoses. The Plan denied your request. The Plan says the principal diagnosis of A41.9 
(Sepsis, unspecified organism), and the secondary diagnosis of G92 (toxic encephalopathy) are not supported 
in the medical record. 
 
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 principal diagnosis of A41.9 (Sepsis, 
unspecified organism), and the secondary diagnosis of G92 (toxic 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 services at the DRG originally billed. Our reviewer says 
that the principal diagnosis of A41.9 (Sepsis, unspecified organism), and the secondary diagnosis of G92 (toxic 
encephalopathy) are not supported in the medical record. Our physician reviewer found that the records 
supported a three-day admission for further evaluation and treatment of pneumonia. The patient's past medical 
history included atrial fibrillation, breast cancer, colon polyp, dementia, diabetes mellitus, and osteoarthritis. 
The patient presented to the hospital with complaints of altered mental status. The emergency room 
documentation stated that the patient was placed on antibiotics for a urinary tract infection (UTI). She also 
recently had an elevated blood glucose. Per the ambulance records, the patient had oxygen (O2) saturations of 
88% on room air and was placed on 3L of supplemental O2 on nasal cannula. Her neurological status was 
documented as alert, awake and appropriate. The history and physical noted that the patient arrived with 
complaints of non-productive cough. Her chest x-ray was consistent with bilateral pneumonia. Her neurological 
status was documented as no focal neurological deficits with patient noted with underlying dementia. 
"Neurological: Alert, awake and appropriate. No facial asymmetry. Normal Speech. No acute focal 
neurological deficits are appreciated. No new focal weakness or paresthesia. CN's II-XII are grossly intact." 
The history and physical exam documentation stated, "Alert, cooperative, no distress, appears stated age. 
Neurologic: Normal, no focal neurological deficit." The progress notes stated, "alert, appears stated age and 
cooperative." Toxic metabolic encephalopathy secondary to UTI and pneumonia, atrial fibrillation, and 
diabetes mellitus. The progress notes noted no fever, no chills, or shortness of breath. A query was sent to the 
treating physician to clarify the diagnosis of sepsis; physician response was sepsis due to pneumonia. Nursing 
flow sheets noted that the patient was disoriented throughout the admission up until the day of discharge. There 
was no change in mental status or improvement with treatment. The discharge summary noted the patient was 
oriented x3; however, this did not support the nursing documentation noted in the flowsheets. Even though 
sepsis is documented, supporting medical record documentation was not found within the record.  
 
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 from November 11, 2020, to November 14, 2020, at the Diagnosis 
Related Group (DRG) originally billed.