Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from December 17, 2020, to 
December 24, 2020, as billed with Diagnosis Related Group (DRG) 682. 
 
You asked the Plan to pay for inpatient care billed with DRG 682. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 682 is not supported as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. The 
Plan argues that DRG 683 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 billed with DRG 682. Our 
reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical records 
for this inpatient admission. Our physician reviewer found that the documentation supports an admission for 
acute kidney failure (AKF). Even though encephalopathy is documented solely in the discharge summary, 
supporting medical record documentation was not found within the record. The enrollee was admitted with 
altered mental status and AKF present because she had not been eating or drinking for 3 days. She was 
documented to have progressive memory loss and progressive difficulty with swallowing. To support a 
diagnosis of acute encephalopathy, documentation must support a change in mental status which is beyond 
baseline and supported by neurological examination findings documented by licensed provider corroboration. 
This requires clear documentation of the enrollees baseline and should be supported by the provider. A 
neurological exam must be consistent with a diagnosis of encephalopathy and should show improvement with 
treatment. The enrollee with progressive memory loss had multiple chronic comorbidities, including vascular 
dementia, type 2 diabetes mellitus, hypertension, and new onset dysphagia as noted on the progress note. An 
MRI of the brain was completed and showed severe chronic small-vessel ischemic change, left lacunar infarct, 
gliosis of the pons, ventricular enlargement and cerebral and cerebellar atrophy with known history of 
dementia. Her poor oral intake is likely due to vascular dementia resulting in failure to thrive with aspiration. 
History and physical documentation report that the enrollee is oriented to person with appropriate mood, and 
she is, "alert, and in no distress". As noted above, although the provider documented metabolic encephalopathy, 
reasonable support within the health record must be present for that diagnosis. The review indicates that the 
medical records did not support the billing of metabolic encephalopathy (G93.41). 
 
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 billed with DRG 682 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from December 17, 2020, to December 
24, 2020, as billed with Diagnosis Related Group (DRG) 682.