Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from June 24, 2021, to 
June 28, 2021, at the Diagnosis Related Group (DRG) billed. 
 You asked the Plan to pay for the inpatient services at the DRG billed. You say that this hospitalization was 
billed correctly. The Plan denied your request. The Plan says the principal diagnosis of N17.9 (Acute kidney 
Failure, unspecified) is not supported in the medical record. Rather, the diagnosis of K20.80 (other esophagitis 
without bleeding) should have been the principal diagnosis because this condition was the one requiring the 
most treatment and was the major focus of care. 
 
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 a principal diagnosis code of N17.9 (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 at 
the DRG billed. Our reviewer says that a principal diagnosis of N17.9 (Acute kidney Failure, unspecified) is 
not supported in the medical record. Our physician reviewer found that the patient arrived as a transfer from an 
outside facility. The history and physical stated that the patient was being admitted with odynophagia and acute 
renal failure. The plan portion of the history and physical stated that a modified barium swallow would be 
ordered, magic mouthwash will be ordered, Maalox and Protonix will be started, and that Gastroenterology 
would be consulted for the diagnosis of odynophagia. The plan also stated that urine studies and a renal 
ultrasound would be ordered, lactated ringers would be started, creatinine levels would be monitored, and that 
Nephrology would be consulted for the diagnosis of acute renal failure. The inpatient admission order stated 
that the patient was admitted to an inpatient level of care for treatment of odynophagia. The patient was seen by 
speech pathology on June 22, 2021, for a fiberoptic endoscopic evaluation of swallowing. On June 23, 2021, a 
diagnostic endoscopic gastro-duodenoscopy with PEG tube placement was performed. The postoperative 
diagnosis was listed as, "radiation esophagitis with non-obstructive stricture at 20cm." The hospital medicine 
progress notes supported that the patient had diagnoses of both odynophagia and acute renal failure. The 
discharge summary lists "odynophagia" as the principal problem and "acute renal failure" as an active problem 
within the list of discharge diagnoses. The submitted documentation supports that the patient was admitted with 
a diagnosis of odynophagia and that the patient was evaluated by speech therapy followed by an EGD with 
placement of a PEG tube by the gastroenterologist. The EGD report noted that the patient was found to have 
radiation esophagitis with a non-obstructive stricture. Although the patient did have diagnoses of both 
odynophagia and acute renal failure, after further evaluation and treatment it was the patient's radiation 
esophagitis that was the major focus of care and the condition that required the most treatment.   
 
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 hospital services provided from June 24, 2021, to June 28, 2021, at the Diagnosis Related Group 
(DRG) billed.