Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for inpatient care as billed with principal diagnosis code A41.9. We 
decided that the Plan does not have to pay for inpatient care as billed with secondary diagnosis code J96.01.  
 
You asked the Plan to pay for inpatient care as billed with diagnosis related group (DRG) 871. You say that 
these services were medically necessary and are supported in the record. The Plan says that DRG 871 is not 
appropriate as the diagnoses of sepsis, unspecified organism (A41.9) and acute respiratory failure with hypoxia 
(J96.01) are not supported in the medical record. The Plan argues that DRG 194 is more appropriate in this 
case. 
 
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. 
 
We decided that the Plan has to pay for inpatient care as billed with principal diagnosis code 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 inpatient care billed with principal diagnosis 
code A41.9. Our reviewer says that the medical records support the billing of sepsis, unspecified organism 
(A41.9). Our physician reviewer found that the enrollee with a history of tobacco dependence presented to the 
hospital with shortness of breath, cough and weakness. The physical exam was notable for fever, tachycardia 
and tachypnea. There was no respiratory distress, wheezes or accessory muscle use. The enrollee was alert and 
oriented x3. Pulse oximetry was 96 percent on room air. Laboratory studies were notable for leukocytosis, 
hyponatremia, hyperglycemia, elevated C-reactive protein and procalcitonin. A chest x-ray was notable for 
mild left lower lobe infiltrate/atelectasis. Intravenous antibiotics were administered. The enrollee met systemic 
inflammatory response syndrome (SIRS) criteria and was admitted to the hospital with a diagnosis of sepsis 
due to pneumonia. The enrollee was admitted to the hospital with diagnoses of sepsis, pneumonia, suspected 
COVID-19, hyponatremia, nicotine dependence, deep vein thrombosis prophylaxis, abnormal 
electrocardiogram, and elevated blood glucose. The infectious disease specialist diagnosed an acute sepsis 
syndrome. The review supports the billing of diagnosis code A41.9. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for billing diagnosis code A41.9 have been met. Therefore, we decided that the Plan has to pay 
for inpatient care as billed with principal diagnosis code A41.9.  
 
We also decided that the Plan does not have to pay for inpatient care as billed with secondary diagnosis 
code J96.01. 
 
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 care as billed with diagnosis code 
J96.01. Our physician reviewer found, based on this same medical review, that the records do not consistently 
support the billing of diagnosis code J96.01. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for billing diagnosis code J96.01 have not been met. Therefore, we decided that the Plan does 
not have to pay for inpatient care as billed with secondary diagnosis code J96.01. 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.