Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services with diagnosis related group 
(DRG) 243 provided from October 1, 2020, to October 5, 2020. 
 You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the 
billing of the secondary diagnosis code N17.0 with DRG 243. The Plan denied your request. The Plan says the 
medical records do not support the billing of the secondary diagnosis code N17.0 with DRG 243. 
 
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 secondary diagnosis code N17.0-Acute kidney 
failure with tubular necrosis. 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. Our reviewer says that the medical records do not support the billing of the secondary 
diagnosis code N17.0 with DRG 243. Our physician reviewer found the review has determined that the enrollee 
presented from the nursing home with weakness and slow pulse. On presentation, the enrollee was found to be 
bradycardic with a 2-1 AV block with narrow QRS complex and underlying sinus bradycardia. Despite this 
slow heart rate, the enrollee felt relatively well denying any shortness of breath or profound weakness. Her 
extremities were noted to be warm and well-perfused on admission. Cardiology was consulted for bradycardia 
secondary to type II second-degree AV block and underlying sinus bradycardia heart rate of 28 beats per 
minute (bpm). Cardiology assessment stated "She is perfusing well although her renal function shows that there 
may be some renal hypoperfusion. There is no hyperkalemia" and "Renal insufficiency creatinine of 3. This 
may be due to apical perfusion although it should be noted that she is on a very large dose of ACE inhibitor 
which we will hold. I do not know her baseline creatinine. Electrolytes are within normal limits". Progress 
notes continued to state renal insufficiency likely due to poor perfusion from bradycardia, which was also 
stated at discharge. The enrollee underwent successful implantation of dual chamber permanent pacemaker and 
remained in the hospital over the weekend to monitor her renal function. The hospital course summary stated, 
"Lab work revealed elevated creatinine of 3.6. Review of lab work in early 2020 showed normal creatinine 
around 1.0. This renal insufficiency was felt to be due to hypoperfusion. Losartan was discontinued". At 
discharge, the physician documented that her creatinine had trended down since admission per daily BMP: 10/1 
3.6, 10/2 3.52, 10/3 2.48, 10/4 2.19, 10/5 2.00. BUN remained elevated throughout the admission despite 
hydration. The review has determined that the medical records did not support the billing of the secondary 
diagnosis code N17.0 with DRG 243.  
 
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 services with diagnosis related group (DRG) 243 provided from October 1, 2020, to 
October 5, 2020.