Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from February 27, 2021, to March 5, 2021 with the reported principal diagnosis G93.41, Metabolic Encephalopathy.
You asked the Plan to pay for inpatient services provided from February 27, 2021, to March 5, 2021 with the reported principal diagnosis G93.41, Metabolic Encephalopathy. The Plan denied your request. The Plan says the determination to re sequence diagnosis code G93.41 as a secondary diagnosis and assign E11.10
(Type 2 diabetes mellitus with ketoacidosis without coma) as the principal diagnosis, consistent with the documentation submitted is upheld.
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 G93.41, Metabolic Encephalopathy. 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 services with the reported principal diagnosis G93.41, Metabolic Encephalopathy. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation indicates that the enrollee presented to the emergency department (ED) on February 27, 2021 with altered mental status, hyperglycemia and evidence of acidosis on arterial blood gas. He was documented lethargic with slowed speech and response times and the Glasgow Coma Scale was noted to be 14. Intravenous fluid resuscitation, intravenous and subcutaneous insulin was administered, and the enrollee was admitted for further workup. The history and physical examination documentation indicated the cause of the enrollee's mental status changes appeared to be more metabolic and encephalopathic and neurology consultation was requested. On consultation, neurology documented, "1. Encephalopathy - Metabolic 2. Visual disturbance. Suspect source of encephalopathy was secondary to the elevated glucose most likely due to patient not taking medications properly." In the discharge summary, the documentation included, "he was noted to have elevated sugars. He states he was not taking his medicines correctly. He did have slight acidosis, was treated for diabetic ketoacidosis (DKA). Patient with persistent cognitive slowing/confusion despite correct DKA, although wife noted some improvement during stay. Neuro attributed encephalopathy to hyperglycemia, noted no evidence CVA on MRI, and no suspicion for TIA. EEG "did not show any obvious source for seizure". The attending and neurology consultant documentation diagnosed the alteration in mental status as metabolic encephalopathy which after study, was determined to be due to hyperglycemia. The review has determined that the principal diagnosis G93.41, Metabolic Encephalopathy, was not supported by 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 inpatient services provided from February 27, 2021, to March 5, 2021 with the reported principal diagnosis G93.41, Metabolic Encephalopathy.