Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 24, 2022, to 
May 30, 2022, 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 this 
patient meets criteria for sepsis and severe sepsis, so the claim should have been paid at the DRG billed. The 
Plan denied your request. The Plan says the billed diagnoses of A41.89 (other specified sepsis) and R65.20 
(severe sepsis without septic shock) are not clinically validated in the medical record. As a result, a lower DRG 
was paid. 
 
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 diagnoses of A41.89 (other specified sepsis) and 
R65.20 (severe sepsis without septic shock). 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 diagnoses of A41.89 (other 
specified sepsis) and R65.20 (severe sepsis without septic shock) are not supported by the medical record. Our 
physician reviewer found this patient presented to the facility with the chief complaint of weakened state, with 
diarrhea and "lower blood pressure than normal." The patient is a resident of the nursing home, with a medical 
history of diabetes, hypertension, hyperlipidemia, pulmonary embolism, cerebrovascular accident (CVA) with 
left sided paralysis, aphasia, and dysphagia. The patient received 2 liters of fluid in the emergency department 
(ED), as well as Rocephin intravenously. The ED provider noted the patient answered limited questions 
appropriately, with a normal cardiovascular exam, normal pulmonary exam with clear lungs and no 
increased work of breathing, normal peripheral perfusion, and warm and dry skin. History and physical 
documentation included the patient has been having intermittent diarrhea for several weeks, with nausea and 
vomiting 2 days earlier, and was lethargic but denied chest pain, fever, chills, or shortness of breath and was 
alert and oriented. The patient's blood pressure "improved" with normal saline. The patient was given IV 
antibiotics for a urinary tract infection growing Providencia Stuartii, with a plan to complete a 5-day course, 
and diarrhea improved during the admission with C diff ruled out. 
 
Per Medscape Internal Medicine, Sepsis  is a life-threatening syndrome usually caused by bacterial infection. 
Sepsis is a response of the body's immune system that results in organ dysfunction or failure. The systemic 
inflammatory response syndrome (SIRS) criteria were recently replaced by the quick Sequential Organ Failure 
Assessment (qSOFA) in 2016, allowing for quick bedside analysis of organ dysfunction in patients with 
suspected or documented infection. The qSOFA score includes a respiratory rate of 22 breaths/minute or more, 
systolic blood pressure of 100 mm Hg or less, and altered level of consciousness. A score greater than 2 is 
associated with poor outcomes. However, due to conflicting data on diagnosing sepsis it has fallen out of favor 
in the 2021 Sepsis guidelines and may be deemed a predictive tool rather than a diagnostic one. For 
completeness, severe sepsis is defined as sepsis complicated by organ dysfunction. The definitions of sepsis 
and septic shock were revised in 2001 and 2021 by the Society of Critical Care Medicine and European Society 
of Intensive Care Medicine; qSOFA and NEWS (National Early Warning Score) are the most used. NEWS is 
derived from measurement of respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of 
consciousness or confusion, and temperature. A score between 0-4 is low risk, 5-6 is medium risk and 7 or 
higher is associated with high risk for sepsis-associated mortality.  Early identification of sepsis scores 
including NEWS (National Early Warning Score), MEWS (Modified Early Warning Score) and SIRS were 
found to be more reliable and predictive than qSOFA. 
 
In this case, there was no clinical or laboratory evidence of sepsis. The review has determined that the 
documentation does not support diagnoses of A41.89 (other specified sepsis) and R65.20 (severe sepsis without septic shock).  
 
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 May 24, 2022, to May 30, 2022, at the Diagnosis Related Group 
(DRG) originally billed.