Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care with diagnosis related group (DRG) 235 provided from January 11, 2021 to January 17, 2021.  You asked the Plan to pay for the inpatient hospital care. You say that the medical records support the billing of the secondary diagnosis code J95.1 with DRG 235. The Plan denied your request. The Plan says the medical records do not support the billing of the secondary diagnosis code J95.1 with DRG 235.  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 J95.1. 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 care. Our reviewer says that the medical records do not support the billing of the secondary diagnosis code J95.1 with DRG 235. Our physician reviewer found the review indicates that the documentation supported an admission for further evaluation and treatment of atherosclerotic heart disease for which a coronary bypass procedure was performed on January 13, 2021. The enrollee was transferred to the Cardiovascular Intensive Care Unit (CVICU) post operatively, intubated, sedated and hemodynamically stable. Vasoactive drips were weaned, and sedative infusions held, and the enrollee was found hemodynamically stable for extubating on the day of surgery. The enrollee was slow to awaken from sedation and arterial blood gas measurements demonstrated respiratory acidosis, which required two doses of Narcan intravenously, after which, successful weaning parameters were obtained, and the enrollee was liberated from mechanical ventilation and extubated to low flow nasal cannula on the day of surgery. The documentation indicated the enrollee utilized his home Continuous positive airway pressure (CPAP) during hours of sleep in the setting of a past medical history to include obstructive sleep apnea. Post-operative chest imaging studies demonstrated atelectasis and incentive spirometry was utilized along with patient mobilization to prevent pulmonary complications. The documentation indicated the enrollee's ability to successfully utilize incentive spirometry, mobilize out of bed and participate in physical therapy sessions, with successful ambulation of 50 feet documented on post-operative day one. Subsequent documentation consistently recorded physical exam findings of no acute distress, unlabored respiration's, symmetrical chest expansion and hemodynamic stability throughout the encounter. Although the enrollee was slow to recover after sedation/anesthesia, this resolved with Narcan administration and successful weaning and liberation from mechanical ventilation was obtained on the day of surgery which would not be considered consistent with the condition of acute pulmonary insufficiency. The review has determined that the medical records did not support the billing of the secondary diagnosis code J95.1 with DRG 235.   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 care with diagnosis related group (DRG) 235 provided from January 11, 2021 to January 17, 2021.