Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 871 provided from October 3, 2021, to October 6, 2021. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of the principal diagnosis code A41.9 for sepsis with DRG 871. The Plan denied your request. The Plan 
says the medical records do not support the billing of the principal diagnosis code A41.9 for sepsis with DRG 
871. 
 
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 principal diagnosis code A41.9. 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 with DRG 871. Our reviewer 
says that the medical records do not support the billing of the principal diagnosis code A41.9 for sepsis with 
DRG 871. Our physician reviewer found the enrollee is with a history of hypertension, chronic obstructive 
pulmonary disease, chronic pain, and metastatic lung cancer, reported to have been in remission and previously 
on Keytruda, presented for evaluation on October 3, 2021, reporting nausea, vomiting, diarrhea, abdominal 
pain and generalized weakness. His spouse reported concern that he may have "gotten into his medications". 
He was also reported to have a history of sundowning ("sundowners"). Triage vital signs, at 15:38 hours, 
included a temperature of 100.4F with a pulse of 98/minute, blood pressure of 112/84 and respirations of 
18/minute with a room air pulse oximetry reading of 97%. Triage Glasgow coma scale score was 15. The 
Glasgow coma scale score was reported to have been 13 at 15:43 hour. The Emergency Department physician 
described the enrollee as having been confused, but in no acute distress. The admitting physician described the 
enrollee as having been alert and oriented to self and hospital setting, confused, and in no distress. The white 
blood cell count was 11.3K/uL with a platelet count of 509K/uL. The hemoglobin level was 13.1g/dL with a 
hematocrit of 39.9%. The serum glucose level was 126mg/dL. The serum creatinine level was 1.1mg/dL with a 
BUN of 61mg/dL. The total bilirubin level was 0.5mg/dL. Serum lactic acid level was 1.2mmol/L. The serum 
procalcitonin level was 23.32ng/mL. Urinalysis revealed 0-to-1 red blood cells, 2-to-5 white blood cells, 
bacteria and trace leukocyte esterase, without nitrite. Chest x-ray revealed no evidence for acute lung process. 
Urine toxicology screen was not obtained/reported. The enrollee was admitted for further evaluation and 
management, receiving intravenous fluids and empiric antibiotics. He required chemical and physical restraints 
due to confusion and agitation. Urine culture and blood culture were without growth. His mental status was 
reported to have been at baseline at the time of discharge on October 6, 2021. He was discharged to home to 
complete a course of oral antibiotics. There was no documentation of sepsis. The review has determined that 
the medical records do not support the billing of the principal diagnosis code A41.9 for sepsis with 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 hospital services with diagnosis related group (DRG) 871 provided from October 3, 2021, to 
October 6, 2021.