Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care with secondary diagnosis code I21.A1 with diagnosis related group (DRG) 377 provided from November 28, 2020 to December 1, 2020.  You asked the Plan to pay for the inpatient hospital care with secondary diagnosis code I21.A1 with DRG 377. You say that the medical records support the billing of the secondary diagnosis code I21.A1 with DRG 377. The Plan denied your request. The Plan says the medical records do not support the billing of the secondary diagnosis code I21.A1 with DRG 377.  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 I21.A1. 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 care with secondary diagnosis code I21.A1 with DRG 377. Our reviewer says that the medical records do not support the billing of the secondary diagnosis code I21.A1 with DRG 377. Our physician reviewer found the review indicates that the documentation supports an admission for further evaluation and treatment of a gastrointestinal (GI) bleed which required a colonoscopy procedure with argon plasma coagulation of a cecal Arteriovenous malformations (AVM). A transfusion with packed red cells was given in the emergency department (ED) for acute blood loss anemia with a pre-transfusion Hgb 6.9 and post transfusion Hgb 8.0. On admission and throughout the encounter, the documentation indicated the enrollee was in no acute distress with regular heart rate and rhythm, no murmurs, or cardiac rubs with adequate peripheral perfusion, normal respiratory rate, and warm and dry skin. The documentation consistently recorded the enrollee as hemodynamically stable, in no acute distress without chest discomfort or shortness of breath with active participation in physical and occupational therapy sessions and underwent the colonoscopy procedure without complications. Review of the medical record from the documentation received was incomplete to reflect a serial rise and fall of cardiac biomarkers with at least one value above the 99% upper reference limit, abnormal echocardiogram findings, new or presumed new significant changes on 12 lead echocardiogram (EKG), abnormal myocardial imaging with wall motion deficits or loss of viable myocardium or cardiac angiography. The review indicates that the medical records do not support the billing of the secondary diagnosis code I21.A1 with DRG 377.   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 hospital care with secondary diagnosis code I21.A1 with diagnosis related group (DRG) 377 provided from November 28, 2020 to December 1, 2020.