Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 28, 2021, to July 
1, 2021, as billed with Diagnosis Related Group (DRG) 689. 
 
You asked the Plan to pay for inpatient care billed with DRG 689. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 689 is not appropriate as the diagnosis of toxic encephalopathy (G92) is not supported in the medical record. The Plan 
argues that DRG 690 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 689. Our 
reviewer says that the diagnosis of toxic encephalopathy (G92) is not supported in the medical record for this 
inpatient admission. Our physician reviewer found that the patient with a history of dementia presented with 
fever and weakness. She had been seen the day prior in urgent care and had been initiated on outpatient 
antibiotic for a urinary tract infection (UTI). Diagnostic workup was done in the hospital, and the enrollee was 
believed to have a UTI due to her initial presentation of weakness, fever, and positive urinalysis. She tested 
negative for COVID-19. Urine culture grew multiple gram-positive organisms. Although the physician was not 
clear whether cultures had been taken before or after the initiation of antibiotics, as the enrollee had been 
started on Macrobid at urgent care. The discharge summary did document possible UTI, and the diagnosis of 
UTI was also confirmed in the physician query, and the UTI was appropriately treated with intravenous 
antibiotics during the admission with the continuation of oral antibiotics after discharge. The emergency 
department stated that the enrollee "presents for slightly increased confusion. Here she is febrile orally, no focal 
neurological deficits although daughter reports she is more globally confused." Neurological exams were 
grossly normal. 
 
The admission history and physical described the enrollee as alert and oriented. Throughout the record it was 
stated that the enrollee was alert and oriented. There was no documentation of the enrollees baseline mental 
status. The discharge summary included only the diagnosis of dementia, and that she was to continue home 
medications. The report of increased confusion came from the daughter, and the physician documented the 
increased confusion as reported by the daughter. While a family member may note altered mental status and 
confusion, this should be clearly corroborated by the provider as a change from a confirmed or presumed 
baseline mental status to support a diagnosis of encephalopathy. There was no noted change in mental status 
during the admission, nor documentation of improvement in mental status/alertness after treatment for UTI. An 
enrollee who comes into the hospital alert and oriented, and is alert and oriented after treatment, likely did not 
experience encephalopathy. The review has determined that the medical records did not support the billing of 
toxic encephalopathy (G92). 
 
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 689 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from June 28, 2021, to July 1, 2021, as 
billed with Diagnosis Related Group (DRG) 689.