Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 7, 2022, to 
January 11, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis of N17.9 (acute kidney failure unspecified) is a valid diagnosis for this encounter based on the 
medical records. The Plan denied your request. The Plan says the diagnosis of N17.9 (acute kidney failure 
unspecified) is not supported in the medical records. As a result, the DRG was updated. 
 
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 diagnosis of N17.9 (acute kidney failure 
unspecified). 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 services at the 
DRG originally billed. Our reviewer says that the diagnosis of N17.9 (acute kidney failure unspecified) is not 
supported in the medical records. Our physician reviewer found the patient was a then, 85-year-old male who 
arrived with generalized weakness. The patient had a past medical history of coronary artery disease (CAD), 
permanent atrial fibrillation, congestive heart failure (CHF), benign prostatic hypertrophy (BPH), mitral 
regurgitation, hyperlipidemia, and stage-3 chronic kidney disease (CKD 3). The emergency department 
physical exam noted the patient was generally weak, neuro status was oriented to person, place, and time, had 
no respiratory distress, breath sounds were clear, and nontender abdomen. The patient's ultrasound of the 
abdomen revealed evidence of hepatic steatosis and probable cirrhosis. The patient's computed tomography of 
the chest revealed pleural effusions and associated atelectasis. Initial labs included Creatinine 2.26, BUN 39, 
glomerular filtration rate 28, lactic acid 2.8, white blood cell count 6.1, and platelet count 169. The patient was 
diagnosed with acute renal failure superimposed on chronic kidney disease, generalized weakness, and chronic 
subdural hematoma. 
 
Per Medscape Internal Medicine, Acute renal failure develops rapidly over a few hours or days. It may be fatal. 
It's most common in those who are critically ill and already hospitalized. Symptoms include decreased urinary 
output, swelling due to fluid retention, nausea, fatigue, and shortness of breath. Sometimes symptoms may be 
subtle or may not appear at all. In addition to addressing the underlying cause, treatments include fluids, 
medication, and dialysis. 
 
In this case, it was acknowledged that the patient had an elevated creatinine level prior to this admission and 
carried a diagnosis of chronic kidney disease. The creatinine level increased more than 0.3 mg/dL from his 
known preadmission baseline. The review has determined that the documentation did not support the diagnosis 
of N17.9 (acute kidney failure unspecified).  
 
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 hospital services provided on January 7, 2022, to January 11, 2022, at the Diagnosis Related 
Group (DRG) originally billed.