Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 11, 2021, to 
October 13, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of principal diagnosis code A41.9 (Sepsis, unspecified organism) with DRG 
872. The Plan denied your request. The Plan says the medical records do not support the billing of principal 
diagnosis code A41.9 (Sepsis, unspecified organism) with DRG 872. 
 
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 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 at the DRG originally billed. Our 
reviewer says that the medical records do not support the billing of principal diagnosis code A41.9 (Sepsis, 
unspecified organism) with DRG 872. Our physician reviewer found the review indicates that the enrollee was 
with a history of cerebral palsy, hyperlipidemia, chronic urinary retention, and migraine who presented with 
shortness of breath and vomiting. History and physical exam documented vital signs of temp 97.9F, pulse 44, 
respiratory rate 22, blood pressure 207/91, and pulse oxygen saturation (SpO2) 97% on room air. The enrollee 
was described as ill-appearing and in no acute distress, normal pulmonary effort, alert and oriented x3, and no 
focal neurologic deficits. Laboratory test results included a white blood count (WBC) 14.3K, platelet count 
416K, BUN 18, creatinine 0.81, total bilirubin 0.5, and lactic acid 3.0. The enrollee's chest x-ray revealed no 
acute cardiopulmonary process. She was diagnosed with lactic acidosis and admitted for further care. 
Treatment included IV fluids and IV antibiotics. Infectious disease consult noted the enrollee had leukocytosis, 
"high lactic acid, she is not in sepsis." While it is acknowledged that the records include a physician-
documented diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs were 
present along with an elevated lactic acid, the clinical findings in the record do not sufficiently support the 
diagnosis of sepsis based on Sepsis 3 criteria. The review has determined that the medical records did not 
support the billing of principal diagnosis A41.9 (Sepsis, unspecified organism) with DRG 872.  
 
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 on October 11, 2021, to October 13, 2021, at the Diagnosis Related 
Group (DRG) originally billed.