Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 11, 2021, to 
June 17, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that ou 
disagree with the Plan's resequencing of the principal diagnosis. The Plan denied your request. The Plan says 
the principal diagnosis of D68.32 (Hemorrhagic disorder due to extrinsic circulating anticoagulants) is not 
supported in the medical record. The cause of the gastrointestinal bleed was documented as secondary to 
circulating anticoagulant, so diagnosis K92.2 (gastrointestinal hemorrhage, unspecified) should have been 
sequenced first. Diagnosis D68.32 is a secondary diagnosis. 
 
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 the principal diagnosis of D68.32 (Hemorrhagic 
disorder due to extrinsic circulating anticoagulants). 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 at the DRG originally billed. Our reviewer says that the billed principal 
diagnosis of D68.32 (Hemorrhagic disorder due to extrinsic circulating anticoagulants) is not supported in the 
medical record. Our physician reviewer found this 70-year-old male was seen in the emergency department 
(ED) complaining of gastrointestinal (GI) Bleed and abdominal pain. He also reports bright red blood per 
rectum. The diagnosis noted on the ED report was  GI hemorrhage, new and required work up. History and 
physical showed the GI bleed, and GI consult serial hematocrit. The GI consult stated: "70-year-old presented 
with hematochezia. He reports the onset of hematochezia yesterday. He had associated generalized abdominal 
pain, nausea, and vomiting, onset yesterday. His last bowel movement was yesterday. He denies any 
constipation, diarrhea, hematemesis, or melena. He reports drinking ETOH every other day until quitting 3 
months ago..." The progress note (PN) states: "Patient asking for pain medication reports his chest hurts belly 
hurts everything hurts. Last bloody bowel movement yesterday. Has not been taking Eliquis stating it costs 600 
dollars last dose was probably 3 weeks ago. GI bleed likely lower. The patient has a history of pulmonary 
embolism and is supposed to be on Eliquis. The patient understands increased risk of thromboembolism and 
death. Celiac artery stenosis/aneurysm: Discussed with Vascular Surgery who recommend aggressive laxatives 
and a months and stress test tomorrow for possible surgery." The review has determined that D68.32 
(Hemorrhagic disorder due to extrinsic circulating anticoagulants) was not supported as the principal diagnosis 
and another diagnosis should have been principal diagnosis.  
 
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 inpatient hospital services provided on June 11, 2021, to June 17, 2021, at the Diagnosis Related Group 
(DRG) originally billed.