Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from November 29, 2020, to December 7, 2020, with diagnosis related group (DRG) 871.  

You asked the Plan to pay for the inpatient hospital care. You say that the medical records support the billing of the principal diagnosis code A41.9 with DRG 871. The Plan denied your request. The Plan says the medical records do not support the billing of the principal diagnosis code A41.9 with DRG 871.  

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 A41.9: Sepsis, unspecified organism. 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 principal diagnosis code A41.9 with DRG 871. Our physician reviewer found the documentation received for review supported an admission for evaluation and treatment of a urinary tract infection. The enrollee reported weakness with a fall prior to admission with subsequent back pain and an inability to get out of bed or take her prescribed medications for days prior to admission. The physical exam findings included a neurological status of alert and oriented x 4, mildly labored respirations, skin warm and dry with 2+ peripheral pulses and atrial fibrillation with rapid ventricular response (RVR). Treatment in the emergency department (ED) included IV fluids, urine, and blood cultures, IV antibiotics, IV Metoprolol and resumption of her cardiac medications. Wound care was consulted and diagnoses of unstageable pressure ulcers with wound care measures were implemented. The documentation further indicated, "Denies any specific complaints such as Upper Respiratory Infection (URI) symptoms, difficulties breathing, or chest pain/pressure. She does note that she has not been able to take her regular medications for days now as she has not been able to get up." Cardiology was consulted for atrial fibrillation with RVR, and Non-ST-elevation myocardial infarction (NSTEMI) and changes were made to her calcium channel blocker medication with continuation of her anticoagulation medications. Further workup for slurred speech and a facial droop on admission demonstrated a cerebral vascular accident (CVA) and the enrollee was continued on her aspirin and Xarelto. Subsequent documentation indicated the enrollee was able to tolerate and actively participate in physical therapy sessions and with further treatment her condition improved to allow for discharge to a skilled nursing facility for further care. There was no documentation of clinical or laboratory evidence of sepsis. The review has determined that the records did not support the billing of DRG 871 with principal diagnosis code A41.9: Sepsis, unspecified organism.   

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 provided from November 29, 2020, to December 7, 2020, with diagnosis related group (DRG) 871.