Appeal type: Inpatient Hospital
Decision: Partially Favorable

 We decided that the Plan has to pay for the inpatient hospital services billed with principal diagnosis code N17.9. We decided that the Plan does not have to pay for the inpatient hospital services billed with principal diagnosis code N17.9, as well as secondary diagnosis codes G92 and A41.9.   You asked the Plan to pay for the inpatient hospital services billed with principal diagnosis code N17.9. You say that it is felt that this admission was billed with the correct DRG. The Plan says that since the reported diagnosis codes are not supported, the billed DRG is not correct.  We decided that the Plan has to pay for the inpatient hospital services billed with principal diagnosis code N17.9.   The Plan follows Medicare rules. Medicare rules say that 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 the inpatient hospital services billed with principal diagnosis code N17.9. Our reviewer says that the record supports the reported principal diagnosis code but does not support the secondary diagnoses. Our physician reviewer found the enrollee is a female with chronic kidney disease (baseline creatinine of 1.8) who presented with weakness, prior diarrhea, nausea, and dehydration. She was admitted after identifying hydronephrosis on imaging and a white blood cell count of 13.   The principal diagnosis is supported in this case because the enrollee's creatinine was elevated by more than 50% from baseline related to her dehydration and hypovolemia and was not fully resolved on admission. Sepsis was not supported as there was no objective signs of infection causing organ damage. Encephalopathy was not described in the notes as present on admission.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services billed with principal diagnosis code N17.9 have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services billed with principal diagnosis code N17.9.   We also decided that the Plan does not have to pay for the inpatient hospital services billed with principal diagnosis code N17.9, as well as secondary diagnosis codes G92 and A41.9.  The Plan follows Medicare rules. Medicare rules say that 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.  As noted above, our reviewer says that the record supports the reported principal diagnosis code but does not support the secondary diagnoses.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services billed with principal diagnosis code N17.9, as well as secondary diagnosis codes G92 and A41.9 have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with principal diagnosis code N17.9, as well as secondary diagnosis codes G92 and A41.9.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.