Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from September 30, 2020, to 
October 1, 2020, 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 medical 
records support payment at the original DRG billed. The Plan denied your request. The Plan says the billed 
principal diagnosis of A41.9 (Sepsis, unspecified organism) and secondary diagnosis of R65.21 (severe sepsis 
with septic shock) are not supported in the medical records, resulting in a lower DRG 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 the principal diagnosis of A41.9 (Sepsis, 
unspecified organism) and secondary diagnosis of R65.21 (severe sepsis with septic shock). 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 of 
R65.21 (severe sepsis with septic shock) billed were not supported in the medical record. Our physician 
reviewer found the patient presented to the facility with the chief complaint of shortness of breath and vomiting 
and was admitted for one day. The record was re-examined for consistent documentation of sepsis, evidence of 
clinical symptoms consistent with a dysregulated response to infection in organs/sites distinct from direct organ 
impact from the localized infection which persist beyond initial fluid management expected in the setting of 
localized infection, and which cannot be easily explained by causes other than infection, and treatment to 
address this diagnosis. These dysregulated response indicators would be expected to persist beyond optimal 
hydration via fluids and would not be easily attributed to other factors or related as direct organ dysfunction in 
the setting of the localized infection. Although you stated the patient had "elevated lactate, tachycardia and 
tachypnea consistent with severe sepsis", it was noted the lactate level dropped from 2.8 to 0.8 in the 
emergency room following initial fluids given for optimal hydration, and you did not describe a state of shock 
to be present nor was the patient supported to be hemodynamically unstable. After reviewing the medical 
record for clinical validation of A41.9 and R65.21 sufficient supporting documentation was not found within 
the submitted medical record to validate this diagnosis based on Sepsis 3 clinical criteria.  
 
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 services provided from September 30, 2020, to October 1, 2020, at the Diagnosis Related 
Group (DRG) originally billed.