Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from June 30, 2021, through July 4, 2021, as billed.

You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the inpatient care as billed. The Plan denied your request. The Plan says the billed principal diagnosis code and billed secondary diagnosis code were not supported in the medical documentation.

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 J44.90, chronic obstructive pulmonary disease, unspecified and secondary diagnosis code assignment of J96.21, acute and chronic respiratory failure with hypoxia. 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 care as billed. Our reviewer says that the billed primary and secondary diagnosis codes are not supported in the medical documentation. Our physician reviewer found that the review indicates that the documentation supported an admission for acute rhinoviral infection. The documentation was inconsistent regarding a diagnosis of chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure with hypoxia. Even though COPD and acute and chronic respiratory failure with hypoxia is documented in the H&P Report, Progress Notes and in the Discharge Summary, supporting medical record documentation was not found within the record. The member was a then 65-year-old female with a history significant for hypertension, obstructive sleep apnea on CPAP and tobacco abuse, who presented to the emergency department (ED) with complaints of shortness of breath and cough. Documentation within the medical record was conflicting regarding the diagnosis of COPD. While COPD was documented in the medical record, other provider documentation was unclear and/or inconsistent regarding this condition.

Equivalently, after review of the submitted medical record, documentation was inconsistent or unclear regarding a diagnosis of acute and chronic respiratory failure with hypoxia. Admitting provider noted that member was actually going to be discharge from the ED but, after returning from the restroom her O2 sats were noted to be 84% on room air. Member's SpO2 was 94% on admission and currently on 2L after O2 stat down to 84% with ambulation. While member presentation warranted consideration of acute and chronic respiratory failure with hypoxia as a diagnosis, there was no evidence of respiration rate over 30 BPM, use of accessory muscles or altered mental status secondary or hypoxia. In addition, blood gases were not indicative of respiratory failure and documentation does not support that member experienced persistent decline in SpO2 breathing the member's usual FIO2 in more than 2 sequential consistent readings. Documentation reflects that member did improve with 2-3L oxygen via nasal cannula. Furthermore, treatment that is consistent with respiratory failure; administration of oxygen, 5L or more, provision of bilevel positive airway pressure and/or mechanical ventilation was not administered.

The review has determined that the documentation did not support the billed principal diagnosis code J44.90, chronic obstructive pulmonary disease, unspecified and secondary diagnosis code assignment of J96.21, acute and chronic respiratory failure with hypoxia.

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 care provided from June 30, 2021, through July 4, 2021, as billed.