Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from April 6, 2021, 
to April 12, 2021, 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 claim should 
be paid at the DRG originally billed. The Plan denied your request. The Plan says the principal diagnosis of 
A41.9 (sepsis, unspecified organism) and secondary diagnosis E46 (unspecified protein-calorie malnutrition) 
are not supported in the medical record. Though fever, tachycardia, and leukocytosis are noted upon 
presentation the tachycardia and fever resolved promptly in the emergency department (ED) with treatment and 
the leukocytosis improved during this admission. There is no evidence of significant physiologic instability. 
Therefore, the medical record received and available for review does not support the condition treated as 
consistent with a systemic infectious process. There is no evidence of mild to moderate subcutaneous fat loss or 
mild to moderate loss of muscle mass. The patient presented with a body mass index (BMI) of 17.875 and did 
receive oral protein supplementation. As a result, the diagnosis of J18.9 (pneumonia, unspecified organism) 
was sequenced as the principal diagnosis and secondary diagnosis of E46 was removed from the claim. 
 
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 secondary diagnosis E46 (unspecified protein-calorie malnutrition). 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 secondary diagnosis E46 (unspecified 
protein-calorie malnutrition) are not supported in the medical record. Our physician reviewer found the 
documentation supported an admission for bilateral pneumonia, community acquired. The patient's mean 
arterial pressure was noted to be less than 70 on two occasions in the ED prior to the 1000ml fluid bolus of NS 
ordered by the provider. After adequate fluid resuscitation there was no evidence of mean arterial pressures less 
than 70. There were no arterial blood gases drawn to calculate p/f ratio during this admission. The patient's 
creatinine was noted to be 0.8 on admission and then 0.5 by discharge. There was no evidence of creatinine 
greater than 1.2. The patient's total bilirubin was noted to be 0.7 on presentation and was not rechecked during 
this admission. There is no evidence of total bilirubin greater than 1.2 during this admission. The patient was 
noted to be alert and oriented during this entire admission with no documentation of Glasgow Coma Scale 
Score in the records submitted for review. The patient's platelet count was noted to be 342 on presentation then, 
288, 285, and 299 with no evidence of platelet count under 150. It is noted that in the nursing flowsheets there 
is urine output calculated by both ml and urine count. On 04/09- 04/10 the urine output is noted to be 350ml 6 
in the urine count column. There is no documentation of low urine output, oliguria, or provider documentation 
of the clinical significance of the urine output in the medical record submitted for review. Though fever, 
tachycardia, and leukocytosis were noted upon presentation, the tachycardia and fever resolved promptly in the 
ED with treatment and the leukocytosis improved during this admission. There was no evidence of significant 
physiologic instability.  
 
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 April 6, 2021, to April 12, 2021, at the Diagnosis Related 
Group (DRG) originally billed.