Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 25, 2021 to 
March 29, 2021, 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 you 
agree with the resequencing of diagnosis J18.9 (pneumonia, unspecified organism) as the principal diagnosis, 
but contends that E43 (unspecified severe protein-calorie malnutrition) is a valid secondary diagnosis for this 
encounter. The Plan denied your request. The Plan says the originally-billed principal diagnosis E43 
(unspecified severe protein-calorie malnutrition) is not appropriate. The principal diagnosis should be J18.9 
(pneumonia, unspecified organism), which was billed as a secondary diagnosis. Diagnosis J18.9 (pneumonia, 
unspecified organism) has been resequenced as the principal diagnosis. Diagnosis E43 (unspecified severe 
protein-calorie malnutrition) was removed, resulting in a lower DRG being 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 a diagnosis of E43 (unspecified severe protein-
calorie malnutrition). 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 billing of E43 ((unspecified severe protein-
calorie malnutrition) as a secondary diagnosis is not supported in the medical record. Our physician reviewer 
found adults generally with protein-energy malnutrition lose weight, although, in some cases, edema can mask 
weight loss. Patients may describe listlessness, easy fatigue, and a sensation of cold. Global impairment of 
system function is present. Patients with protein-energy malnutrition can also present with non-healing wounds. 
This may signify a catabolic process that requires nutritional intervention. The review indicates that this patient 
was admitted with a diagnosis of pneumonia. There was a documented weight loss of greater than 5%  in 1 
month.  The principal diagnosis should be J18.9 (pneumonia, unspecified organism), which was billed as a 
secondary diagnosis. Diagnosis J18.9 (pneumonia, unspecified organism) has been resequenced as the principal 
diagnosis. Diagnosis E43 (unspecified severe protein-calorie malnutrition) was removed, resulting in a lower 
DRG being paid. While E43 (unspecified severe protein-calorie malnutrition) is a valid diagnosis for this 
encounter, it is not the principal diagnosis. The review has determined that the Plan justified in removing 
diagnosis E43 (unspecified severe protein-calorie malnutrition)  
 
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 March 25, 2021 to March 29, 2021, at the Diagnosis Related Group 
(DRG) originally billed.