Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with secondary diagnosis code 
D62 and diagnosis related group (DRG) 454 provided from October 19, 2020, to October 23, 2020. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of secondary diagnosis code D62 with DRG 454. The Plan denied your request. The Plan says the 
medical records do not support the billing of secondary diagnosis code D62 with DRG 454. 
 
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 D62. 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 services. Our reviewer says that the medical records do not support the 
billing of secondary diagnosis code D62 with DRG 454. Our physician reviewer found the review revealed this 
enrollee presented to the facility for an elective L4-L5 spinal fusion procedure in the setting of degenerative 
lumbar spondylolisthesis and stenosis. The enrollee was acknowledged to have a hemoglobin of 12.1 and 
hematocrit of 36.3 prior to the surgical procedure based upon laboratory data from one week prior to the 
procedure. The operative note revealed the enrollee underwent the procedure without documentation of 
excessive or unexpected bleeding, with an estimated blood loss of 50 cc. It was acknowledged the enrollee had 
an isolated routinely order complete blood count ordered on day one of admission on October 19, 2022, that 
revealed a hemoglobin of 10.4 and a hematocrit of 33.4, however these findings are of unclear significance as 
the provider did not clarify a source of blood loss, nor was any further monitoring or investigation into methods 
to stop bleeding was found in the record. The progress notes stated blood counts would be monitored however 
no further lab results were present in the record and no provider support of treatment to address a cause of 
anemia was described. Symptoms or impact of the hemoglobin/hematocrit values was not described in the 
record, the enrollee was described as "asymptomatic" related to the findings. Color was described as pink, heart 
rates were primarily less than 90, and the mean arterial blood pressures were greater than 70 mmHg with 
saturation values greater than 95% and peripheral perfusion examinations were within normal limits. The 
discharge summary noted no follow up or treatment plans related to the hemoglobin/hematocrit, with routine 
follow up with the surgeon only. The review has determined that the medical records did not support the billing 
of secondary diagnosis code D62 with DRG 454.  
 
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 with secondary diagnosis code D62 and diagnosis related group (DRG) 454 
provided from October 19, 2020, to October 23, 2020.