Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 30, 2021, to 
February 4, 2021, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient care billed with DRG 872. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 872 is not supported as the diagnoses of sepsis due to other specified staphylococcus (A41.1) and severe sepsis without 
septic shock (R65.20) are not supported in the medical record. The Plan argues that DRG 690 is more 
appropriate in this case, and the diagnosis of urinary tract infection, site not specified (N39.0) should be re-
sequenced as the principal diagnosis. 
 
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 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 DRG 872. Our 
reviewer says that the diagnoses of sepsis due to other specified staphylococcus (A41.1) and severe sepsis 
without septic shock (R65.20) are not supported in the record for this inpatient admission. Our physician 
reviewer found the enrollee resented to the ER with complaints of fever, chills, and generalized weakness. The 
enrollee's past medical history included depression, dementia, gastroesophageal reflux disease (GERD), gait 
instability, deep vein thrombosis (DVT) and hypertension. In the ER, the enrollee was in no acute distress and 
was noted to be at baseline mental status which was alert and oriented x2. Vital signs noted a temperature of 
99.5, a pulse of 93, a respiratory rate up to 22, a blood pressure of 149/64, and an oxygen concentration of 
98%. The enrollee was diagnosed with a urinary tract infection (UTI) and an occult large intestine infection 
versus an adverse reaction and superficial skin infection from COVID 19 vaccine. Review of the laboratory 
data revealed an initial creatinine of 2.7; however, documentation indicated that acute kidney injury (AKI) was 
secondary to prerenal failure as the creatinine improved with IV fluids. In addition, the patient was suspected of 
having underlying chronic kidney disease (CKD) stage 2, and no clear baseline was provided. The initial total 
bilirubin was 0.7 and the platelet count was 154. There was no additional evidence found on review to support 
a diagnosis of sepsis. The review has determined that the medical records did not support the billing of sepsis 
due to other specified staphylococcus (A41.1) and severe sepsis without septic shock (R65.20). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 872 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 30, 2021, to February 4, 
2021, as billed with Diagnosis Related Group (DRG) 872.