Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided on July 24, 2020, with the reported principal diagnosis A41.9, sepsis, unspecified organism.  You asked the Plan to pay for inpatient services provided on July 24, 2020, with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says the documentation supported an admission for Sepsis and Paroxysmal Atrial Fibrillation. From the information that was received, documentation was inconsistent or unclear regarding a diagnosis of pneumonia. Even though probable pneumonia is listed in the history and physical examination (H&P), discharge summary, and consult notes, the supporting documentation was not found within the submitted medical record.  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 A41.9, sepsis, unspecified organism. 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 services provided on July 24, 2020, with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation supported an admission for sepsis and paroxysmal atrial fibrillation. The documentation was inconsistent or unclear regarding a diagnosis of pneumonia. Even though "probable pneumonia" was listed in H&P, discharge summary, and consult notes, the supporting documentation was not found within the submitted medical record. The appeal letter argues pneumonia based on shortness of breath, chest pain, and fever. Although probable pneumonia was documented, the enrollee's respiratory status was documented as "Lungs were clear to auscultation, respirations were non-labored" by the emergency department (ED) provider; and "Lungs are clear to auscultation, respirations are non-labored, breath sounds were equal" by the admitting provider on the H&P. Respiratory rate remained between 16-20. In addition, the chest x-ray showed "no acute cardiopulmonary process". Finding suggested "Lungs are normally expanded. No airspace disease or pleural abnormality noted". Imaging confirmation of pneumonia was not present during this admission. As noted above, although the provider documented pneumonia, reasonable support within the health record must be present for the diagnoses. The review has determined that the principal diagnosis A41.9, Sepsis, unspecified organism, was not supported by the medical records.  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 services provided on July 24, 2020, with the reported principal diagnosis A41.9, sepsis, unspecified organism.