Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from June 6, 2021, to June 
10, 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 appropriate as the diagnosis of sepsis due to Escherichia coli (A41.51) is not supported in the medical record. 
The Plan argues that DRG 690 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 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 diagnosis of sepsis due to Escherichia coli (A41.51) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found that the enrollee presented with fever, 
weakness, and a fall at home. The emergency department exam documented vital signs of temp 100.2F, pulse 
82, respiratory rate 20, blood pressure 117/60 and pulse oxygen saturation (SpO2) 98% on room air. The 
enrollee was described as in no acute distress, no respiratory distress, normal pulmonary effort, alert, and with 
no focal neurologic deficits. Laboratory test results included a white blood cell count of 14.8K, platelet count 
of 208K, creatinine of 0.85, and lactic acid 1.5. The enrollees chest x-ray showed no acute process. The 
enrollees computed tomography (CT) of the head revealed no acute process. The physician documented that 
the enrollees urinary catheter specimen showed obvious infection, but the culture results were pending. 
Ultimately the culture returned positive for Escherichia coli. She was diagnosed with a urinary tract infection 
(UTI) and admitted for further care. Treatment included IV fluids and IV antibiotics. History and Physical 
noted the enrollees neurological status was alert and oriented three times. A query was sent to the physician to 
clarify sodium level and returned with a diagnosis of hypernatremia. While it was 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 did 
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 sepsis due to Escherichia coli (A41.51). 
 
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 June 6, 2021, to June 10, 2021, as 
billed with Diagnosis Related Group (DRG) 872.