Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from July 26, 2021, 
to July 30, 2021. 
 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 G93.41 with DRG 064. The Plan denied your request. The Plan says the 
medical records do not support the billing of the secondary diagnosis code G93.41 with DRG 064. 
 
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 G93.41. 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 G93.41 with DRG 064. Our physician reviewer found the 
review indicates that the enrollee, with a history of dementia, cerebrovascular accident, congestive heart failure, 
hypertension, stage III chronic kidney disease, and gout, who presented for evaluation July 26, 2021, with 
reported worsening forgetfulness and slurred speech. Triage vital signs included a temperature of 97.7F with a 
pulse of 58/minute, blood pressure of 203/97 and respirations of 18/minute with a room air pulse oximetry 
reading of 97%. The Glasgow coma scale score was reported to have been 15. The Emergency Department 
physician described the enrollee as knowing his "name, birthday and wife. At baseline per wife but speech is 
mildly slurred". The white blood cell count was 5.9K/uL with a hemoglobin of 11.8g/dL, hematocrit of 36.9% 
and platelet count of 245K/uL. The blood glucose level was 112mg/dL. The serum sodium level was 
138mmol/L, with a calcium of 9.1mg/dL, total CO2 of 28mmol/L, creatinine of 1.6mg/dL with a BUN of 
28mg/dL. Computed tomography (CT) scan of the head revealed progression of microangiopathy, without 
evidence of acute intracranial abnormality. Brain Magnetic resonance imaging (MRI) revealed an acute left 
pontine stroke. The enrollee was admitted for further evaluation and management, receiving blood pressure 
control. Neurology consultation was obtained; the enrollee was described as having been alert and oriented in 
two fields, with intact speech and language. On July 28, 2021, the enrollee was described as having been 
oriented in three fields. This enrollee experienced a transient alteration in mental status in the setting of acute 
lacunar infarction. The hospital record did not support reporting the diagnosis code for Metabolic 
encephalopathy in this case. The review has determined that the medical records did not support the billing of 
the secondary diagnosis code G93.41 with DRG 064.  
 
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 provided from July 26, 2021, to July 30, 2021.