Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided May 27, 2020 to June 12, 2020 billed with DRG 871.  You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 A41.51 defined as sepsis due to Escherichia coli (E. coli), G93.41 (metabolic encephalopathy), J18.9 (pneumonia, unspecified organism) and J96.21 (acute and chronic respiratory failure with hypoxia). 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. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the enrollee was accepted in transfer to complete a course of intravenous antibiotics and to receiving restorative Physical and Occupational Therapy, having been admitted to an Acute Care Hospital with a diagnosis of sepsis due to Escherichia coli. At the time of admission to the Long Term Acute Care Facility (LTAC), the patient was described as having been awake, alert and oriented in three fields. Acute encephalopathy was reported to have resolved by the time of transfer to the LTAC. Acute on chronic respiratory failure with hypoxia was also reported to have resolved prior to transfer to the LTAC. Likewise, the patient was reported to have completed a course of antibiotics for recent pneumonia. The patient was to continue a course of intravenous antibiotics for urinary tract infection with Escherichia coli bacteremia and for left shoulder septic arthritis. The enrollee was also to receive Physical and Occupational Therapy. The enrollee was ultimately discharged to a Skilled Nursing Facility. Given that the long term acute care admission history and physical examination report indicated that acute encephalopathy, acute on chronic respiratory failure with hypoxia and pneumonia had resolved prior to transfer to the long term acute care, and were therefore no longer active acute conditions, the corresponding diagnosis codes were disallowed. Likewise, as Sepsis had resolved prior to transfer to the long term acute care, the diagnosis code for Sepsis due to E. coli was disallowed as not being an active condition. Chronic respiratory failure with hypoxia is appropriately reported. The review of the documentation has determined that the documentation does not support the billing of DRG 871.   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 May 27, 2020 to June 12, 2020 billed with DRG 871.