Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 9, 2023, to 
January 17, 2023, 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 the 
diagnoses billed are supported by the medical record. The Plan denied your request. The Plan says the billed 
diagnosis code of A41.9 (sepsis, unspecified organism) is not supported by the medical record. The more 
appropriate principal diagnosis is respiratory syncytial virus pneumonia (J12.1). In addition, the billed 
secondary diagnosis codes of J96.01 (acute respiratory failure with hypoxia) and J15.1 (Pneumonia due to 
Pseudomonas) are also not billed appropriately. 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 primary diagnosis code A41.9 (sepsis, unspecified 
organism) and secondary diagnosis codes of J96.01 (acute respiratory failure with hypoxia) and J15.1 
(Pneumonia due to Pseudomonas). 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 primary diagnosis code of 
A41.9 (sepsis, unspecified organism) and secondary diagnosis codes of J96.01 (acute respiratory failure with 
hypoxia) and J15.1 (Pneumonia due to Pseudomonas) are not supported by the medical record. Our physician 
reviewer found the enrollee is an 80-year-old female with asthma and pulmonary fibrosis who presented to the 
hospital and was treated for respiratory syncitial virus (RSV) pneumonia. Workup and evaluation throughout 
the hospital stay revealed no hypotension, normal bilirubin, baseline mental status, normal creatinine, normal 
platelet count, no oliguria, procalcitonin of 0.10, and SpO2 90% or higher on room air at rest and down to 87% 
at lowest with ambulation or talking continuously and tolerated low dose oxygen support. The notes described 
the enrollee not requiring vent support, high flow oxygen, or Bilevel positive airway pressure (BiPAP), or have 
respiratory distress with expected mild hypoxia expected considering the enrollee's chronic condition and 
pneumonia diagnosis. The testing suggested only a virus pneumonia and not a bacterial pneumonia, without 
evidence of bacterial sputum culture supporting Pseudomonas. Therefore, the code, J15.1 (pneumonia due to 
Pseudomonas) is not supported for this admission. Also, the enrollee did not have sufficient evidence of acute 
respiratory failure to justify the code, J96.01 (acute respiratory failure with hypoxia). Also, the Sepsis-3 criteria 
was not met as there was insufficient evidence of organ failure directly related to a dysregulated response to 
infection. Therefore, the code, A41.9 (sepsis) is also not supported for this admission.   
 
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 January 9, 2023, to January 17, 2023, at the Diagnosis Related 
Group (DRG) originally billed.