Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 27, 2021, to 
April 1, 2021, as billed with Diagnosis Related Group (DRG) 871. 
 
You asked the Plan to pay for inpatient care as billed with DRG 871. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 871 is not appropriate as the diagnosis of other specified sepsis (A41.89) is not supported in the medical record. The 
Plan argues that DRG 193 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 as billed with DRG 871. Our 
reviewer says that he diagnosis of other specified sepsis (A41.89) is not supported in the medical record for this 
inpatient admission. Our physician reviewer found that the enrollee with a history of cerebrovascular accident 
with multiple extremity contractures, coronary artery disease, congestive heart failure, hypertension, and left 
foot ulceration, presented for evaluation on March 27, 2021, reporting wheezing and symptoms of a cold. The 
Emergency Department physician described the enrollee as having been awake, alert and oriented to person, 
place and time, with decreased breath sounds. The admission History and Physical examination report 
described the enrollee as chronically ill-appearing. Urinalysis was without evidence of infection and a chest x-
ray revealed moderate left lung alveolar consolidation and mild right lung alveolar consolidation. Computed 
Tomography (CT) scan of the thorax revealed moderate-to-large bilateral pleural effusions with passive 
atelectasis and patchy ground-glass upper lobe opacities. CT scan of the abdomen and pelvis revealed gall 
stones and a suggestion of porcelain gallbladder. While in the Emergency Department, the enrollee received 
bronchodilator mediation, intravenous steroids, Lasix and empiric intravenous antibiotics. She was admitted for 
further evaluation and management of pneumonia and exacerbation of congestive heart failure. Abdominal 
ultrasound revealed a contracted gallbladder with gall stones. Echocardiogram revealed a left ventricular 
ejection fraction of 63%. The urine culture was without growth and one of two blood culture bottles returned 
with growth of Coagulase negative. There was no clinical or laboratory evidence of sepsis. The review has 
determined that the medical records did not support the billing of other specified sepsis (A41.89). 
 
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 as billed with DRG 871 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient hospital care provided from March 27, 2021, to April 1, 
2021, as billed with Diagnosis Related Group (DRG) 871.