Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 7, 2022, to May 
12, 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 
claim was billed correctly. The Plan denied your request. The Plan says the medical records do not sufficiently 
document the billed diagnoses of A41.89 (other specified sepsis) or J96.01 (acute respiratory failure with 
hypoxia). 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) or 
J96.01 (acute respiratory failure with hypoxia). 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 diagnoses of A41.89 
(other specified sepsis) or J96.01 (acute respiratory failure with hypoxia) are not supported by the medical 
record. Our physician reviewer found the enrollee was a then, 62-year-old female, with history of depression, 
asthma, hypertension and gastroesophageal reflux disease, who was transferred on May 07, 2022, for further 
evaluation and management, having presented elsewhere reporting dyspnea. Computed tomographic (CT) 
angiogram of the thorax at the transferring facility reportedly revealed bilateral infiltrates. The high-sensitivity 
troponin level was reported to have been elevated, prompting transfer. The earliest vital signs documented at 
the accepting facility, at 10:00 hours on May 07, 2022, revealed a pulse of 99/minute blood pressure of 139/58 
and respirations of 24/minute with a pulse oximetry reading of 97% while receiving nasal oxygen at 4L/minute; 
her temperature was 98.9F. The Admission History and Physical Examination report described the patient as 
having been alert and oriented to person place and time and not ill-appearing. The white blood cell count was 
11.3K/uL with a platelet count of 170K/uL. The hemoglobin level was 10.8g/dL with a hematocrit of 33.8%. 
The serum glucose level was 152mg/dL. The serum creatinine level was 0.76mg/dL with a BUN of 14mg/dL. 
The total bilirubin level was 0.5mg/dL. The serum lactic acid level was 1.5mmol/L. Single view chest x-ray 
revealed mild vascular engorgement, without overt edema or focal infiltrate. The patient was treated with 
Ceftriaxone and Azithromycin, aerosolized bronchodilator medication, Dulera, steroids, and supplemental 
nasal oxygen. Acute coronary syndrome/non-ST elevation myocardial infarction was ruled out. 
 
In this case, there was no clinical or laboratory evidence of sepsis. Regarding the patients respiratory status, 
the patient was receiving nasal oxygen at 5L/minute, and the hospital flow-sheets document that nasal oxygen 
was provided at 4L/minute on May 07, 2022. Nasal oxygen was continued at 3L-to-4L/minute on May 08, 
2022, and May 09, 2022. Nasal oxygen was reduced to 2L/minute on May 10, 2022, and May 11, 2022. She 
was transitioned to room air on May 12, 2022.  
 
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 7, 2022, to May 12, 2022, at the Diagnosis Related Group 
(DRG) originally billed.