Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 20, 2020, to 
September 26, 2020, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not appropriate as the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record. The 
Plan argues that DRG 603 is more appropriate in this case. 
 
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. 
 
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 inpatient care billed with DRG 872. Our 
reviewer says that the diagnosis of sepsis, unspecified organism (A41.9) is not supported in the medical record 
for this inpatient admission. Our physician reviewer found that the documentation supports an admission for 
cellulitis of the right lower limb. From the information that was received, documentation was inconsistent and 
unclear regarding a diagnosis of sepsis. Even though sepsis is documented on the emergency department 
record, supporting medical record documentation was not found within the record. Of note, sepsis was not 
documented on the history and physical admission note nor was it listed as a diagnosis on the discharge 
summary. The enrollee has a history of hypertension, chronic obstructive pulmonary disease, cellulitis, and 
rheumatoid arthritis for which she takes the immunosuppressive medication Arava. She presented to the 
emergency department with complaints of right leg pain likely cellulitis. While member presentation warranted 
consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a 
dysregulated host response to infection. The member remained alert and oriented, and her total bilirubin was 
0.6. There was no arterial blood gas, or a requirement of oxygen noted. Her initial blood pressure of 95/58 
improved after fluid challenge; there was no documentation of persistent hypotension or a mean arterial 
pressure (MAP) <70. Creatinine on admission was 2.08 with improvement to 0.43 after study and her urinary 
output remained stable. Although her platelets remained below 150 throughout her hospital stay, there was no 
clear documentation of a regimen plan directed towards the treatment of low platelets. Her Arava was held 
during her stay. There must be a rise of 2 or more points in the Sequential Organ Failure Assessment (SOFA) 
score that cannot be easily explained by causes other than sepsis. Systemic inflammatory response syndrome 
(SIRS) criteria are an appropriate response to infection. Though leukocytosis and a lactic acid level of 2.9 was 
noted upon presentation, her white blood cell count promptly improved with treatment in the emergency 
department. There was no follow up lactic acid level noted and no evidence of significant physiologic 
instability. The review has determined that the medical records did not support the billing of sepsis, unspecified 
organism (A41.9). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from September 20, 2020, to September 
26, 2020, as billed with Diagnosis Related Group (DRG) 872.