Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 8, 2021, to 
September 13, 2021, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care billed with DRG 682. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not supported as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 684 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 682. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found that the enrollee, an alcohol abuse residential facility 
resident with a history of hypertension and gout, was referred for evaluation on September 8, 2021, after 
facility staff found him to be difficult to arouse and confused. Triage vital signs included a temperature of 
98.4F with a pulse of 109 per minute, blood pressure of 108/71 and respirations of 18 per minute with a room 
air pulse oximetry reading of 96%. Triage nursing notes described the enrollee as having been alert and 
oriented in four fields, with a Glasgow coma scale score of 15. The Emergency Department physician 
described the enrollee as having been alert, with normal mood and behavior, in no acute distress. The enrollee 
was consistently described as having been alert and oriented in all fields throughout the hospital admission. The 
Hospital's assertion in support of the diagnosis code for metabolic encephalopathy rests entirely on the report 
from the residential alcohol treatment facility of the enrollee having been difficult to arouse and having been 
confused. However, as reflected in the triage notes, this enrollee was alert and oriented in four fields, with a 
Glasgow coma scale score of 15 on presentation to the Emergency Department. This finding was corroborated 
by the Emergency Department physician who described the enrollee as having been alert and oriented in four 
fields, and echoed by the Admitting physician, who described the enrollee as having been alert and oriented in 
three fields. While this enrollee may have exhibited an alteration in mental status while at the Residential 
Treatment Facility, his mental status was intact and at baseline on presentation to the Emergency Department 
and through the entire hospital encounter. The review has determined that the medical records did not support 
the billing of metabolic encephalopathy (G93.41). 
 
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 682 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from September 8, 2021, to September 
13, 2021, as billed with Diagnosis Related Group (DRG) 682.