Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 30, 2021, 
to December 11, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that these 
diagnoses are supported by the medical records. The Plan denied your request. The Plan says the principal diagnosis code of A41.50 (unspecified Gram-negative sepsis), and secondary diagnosis codes of A41.89 (Other 
unspecified sepsis) and J15.9 (Pneumonia due to other aerobic Gram-negative bacteria) are not supported in the 
medical record.  Removal of these diagnoses resulted in a lower DRG being paid. 
 
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 principal diagnosis code of A41.50 (unspecified 
Gram-negative sepsis), and secondary diagnosis codes of A41.89 (Other unspecified sepsis) and J15.9 
(Pneumonia due to other aerobic Gram-negative bacteria). 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 at the DRG originally billed. Our reviewer says that the billed principal 
diagnosis code of A41.50 (unspecified Gram-negative sepsis), and secondary diagnosis codes of A41.89 (Other 
unspecified sepsis) and J15.9 (Pneumonia due to other aerobic Gram-negative bacteria) are not supported in the 
medical record.  
 
Our physician reviewer found the enrollee was a 83-year-old female, with a history of congestive heart failure, 
hypertension and oxygen-requiring chronic obstructive pulmonary disease (2L/minute at baseline), who 
presented for evaluation reporting fatigue, generalized weakness, cough and dyspnea. Triage vital signs 
included a temperature of 98.9F with a pulse of 95/minute, blood pressure of 178/90 and respirations of 
16/minute with a pulse oximetry reading of 100% while receiving nasal oxygen at 2L/minute, as low as 85% on 
room air with recovery to 93% with replacement of nasal oxygen. The Glasgow coma scale score was 15. The 
Emergency Department physician described the patient as having been alert and oriented to person, place and 
time. The Admitting physician described the patient as having been ill-appearing; alert and oriented to person, 
place and time with mental status at baseline. The white blood cell count was 30.2K/uL with a platelet count of 
290K/uL. The hemoglobin level was 12.3g/dL with a hematocrit of 38.4%. The serum glucose level was 
113mg/dL. The serum creatinine level was 0.90mg/dL with a BUN of 16mg/dL. The total bilirubin level was 
0.8mg/dL. Serum lactic acid was 0.9mmo/L. The serum ProBNP level was 5,375pg/mL. Urinalysis was 
unremarkable. COVID-19 testing was negative. Influenza testing was negative. Staphylococcus 
aureus/Methicillin-resistant Staphylococcus aureus DNA probes were negative. Chest x-ray revealed 
hyperinflation consistent with chronic obstructive pulmonary disease (COPD) and chronic bilateral interstitial 
lung changes without discreet focal consolidation or effusion.  
 
Computed Tomographic angiogram of the thorax revealed mild cardiomegaly, moderate-to-severe emphysema, 
and a few scattered right lower lobe tree-in-bud airspace opacities suggestive of atypical infection versus 
aspiration pneumonitis. The patient was admitted for the further evaluation and management of pneumonia, 
COPD exacerbation and acute congestive heart failure, receiving intravenous antibiotics, bronchodilator 
medication, intravenous Lasix and supplemental nasal oxygen at 1L-to-3L/minute. The hospital course was 
marked by new onset atrial fibrillation with rapid ventricular response, managed with Diltiazem and 
Amiodarone. She underwent fiberoptic bronchoscopy with bronchoalveolar lavage with findings consistent 
with bronchiectasis, severe bronchitis and severe mucous plugs throughout the tracheobronchial tree. 
Cultures/gram-stain revealed no evidence of Acid-fast bacillus or pneumocystosis, with rare Candida 
albicans/dubliniensis. There was no documentation of microbial evidence for gram negative or gram-positive 
organism. Urine and blood cultures were without growth. The patient was discharged to home to continue nasal 
oxygen at 2L/minute. 
 
Per Medscape Internal Medicine, Sepsis  is a life-threatening syndrome usually caused by bacterial infection. 
Sepsis is a response of the body's immune system that results in organ dysfunction or failure. The systemic 
inflammatory response syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure 
Assessment (qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in patients with 
suspected or documented infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, systolic blood pressure of 100 mm Hg or less, and altered level of consciousness.  For completeness, severe 
sepsis is defined as sepsis complicated by organ dysfunction. 
 
In this case there was no clinical or laboratory evidence of gram-negative sepsis. The patient did not exhibit 
evidence of life-threatening organ dysfunction related to a dysregulated host response to infection. She did not 
exhibit persistent hypotension or ongoing hemodynamic instability. Her mental status was intact and at 
baseline.  
 
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 services provided on November 30, 2021, to December 11, 2021, at the Diagnosis Related 
Group (DRG) originally billed.