Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 23, 2021, to 
June 27, 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 this 
admission was billed correctly. The Plan denied your request. The Plan says the principal diagnosis of A41.9 
(sepsis, unspecified organism) is not supported in the medical record. 
 
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). 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 principal diagnosis of A41.9 (sepsis, unspecified organism) is 
not supported in the medical record. Our physician reviewer found the patient presented to the facility with the 
chief complaint of fever, cough and weakness. The emergency provider and history and physical 
documentation supported this patient had a chest radiograph positive for aspiration pneumonia, however the 
patient was also described as "not ill appearing", with "stable" blood pressures documented. The following 
clinical validation criteria were not supported: The patient was described as alert and oriented during the 
encounter and was able to participate in the review of systems and Glasgow coma scale score was recorded at 
15 consistently. The patient's blood pressure was described as "stable" by the provider, and the mean arterial 
blood pressure was noted to be greater than 70 mmHg. The patient's laboratory data revealed platelet counts 
were greater than150K. Following fluids given at 50cc/hr, the patient's total bilirubin level was less than 1.2, 
and the patient's liver function tests were described as "normal." The patient was described as having chronic 
kidney disease stage IV, and although the creatinine was 1.7 mg/dL at admission, following fluids the 
creatinine was consistent at 1.4 and described to be "stable". The provider documentation was inconsistent with 
sepsis, as while the Nephrology consult initially stated the diagnosis, the attending provider did not support the 
diagnosis in the notes, and the post discharge query initiated did not include clinical context from the provider 
that clarified the gaps in documentation within the record related to acute organ dysfunction from a systemic 
response infection.  
 
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 June 23, 2021, to June 27, 2021, at the Diagnosis Related Group 
(DRG) originally billed.