Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided November 5, 2020 to November 10, 2020 billed with secondary diagnosis N17.9, (Acute kidney failure, unspecified).
You asked the Plan to pay for the inpatient services billed with secondary diagnosis N17.9. 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 secondary diagnosis code, N17.9, defined as Acute kidney failure, unspecified. 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 billed with secondary diagnosis N17.9. Our reviewer says that the DRG billed is not supported by the documentation. Our physician reviewer found the documentation supported an admission for further evaluation and treatment of a small bowel obstruction which required an exploratory laparotomy with lysis of adhesions and enterorrhaphy. While documentation of acute kidney failure was noted in the query response, other medical record documentation evidence was incomplete regarding this condition. On admission, the emergency department diagnostic information included a serum creatinine level of 1.4 mg/dL with an estimated glomerular filtration rate 53 ml/min /L. An intravenous fluidbolus, followed by continuous fluids, intravenous narcotics, antiemetics and antibiotics were administered. Subsequent labsrepeated approximately eight hours later showed the serum creatinine decreased to 1.1 mg/dL. Other serum levels checked during the encounter were reported as 0.8 mg/dL. The documentation supported the initial serum creatinine level decrease in response to IV fluid administration and consistently noted the enrollee as voiding well without issue. The documentation received was incomplete to reflect any prospective increase in serum creatinine, significant oliguria/anuria, or an increase in 1.5 times a known or assumed baseline creatinine level consistent with a condition of acute renal failure during this encounter. In this case, the documentation was incomplete to substantiate a condition of acute kidney failure. The review has determined that the secondary diagnosis code N17.9, (Acute kidney failure, unspecified) was not supported by the documentation. The correct DRG was not billed based on the medical records. 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 November 5, 2020 to November 10, 2020 billed with secondary diagnosis N17.9, (Acute kidney failure, unspecified).