Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on January 31, 2023, to 
February 6, 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 sepsis 
unspecified organism and severe sepsis without septic shock are the correct principal and secondary diagnoses. 
The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical validation 
audit shows that the provider has reported inpatient hospital services with the incorrect DRG. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism, and secondary diagnosis code, R65.20, defined as 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 the services at issue in this case were not supported by the medical 
records. Our physician reviewer found the enrollee was treated in the hospital for pneumonia/pneumonitis. 
Records from this visit describe the enrollee presented with fever, cough, shortness of breath, and nasal 
congestion. Workup revealed creatinine (Cr) 2.1 (baseline 1.7). However, it was noted that the enrollee was 
alert and oriented, didn't have oliguria, had normal platelet count, stable blood pressure, oxygen saturation 
(SpO2) was 96%, and there was no bilirubin or arterial blood gas readings to review to determine if abnormal. 
The enrollee was started on antibiotics, as well as a Bi-level positive airway pressure (BiPAP) for work of 
breathing and wheezing related to the pneumonia and congestive heart failure. The Sepsis 3 criteria was not 
met based on the provided documentation as there was not an objective sequential organ failure assessment 
(SOFA) score of 2+, as required. There was insufficient evidence that the enrollee was experiencing organ 
failure directly related to a dysregulated response to systemic infection. The documentation does not support 
A41.9 - sepsis unspecified organism - as the principal diagnosis or R65.20 - severe sepsis without septic shock 
- as the secondary diagnosis for this admission. Therefore, the more appropriate DRG is 177 based on the 
provided documentation.  
 
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 31, 2023, to February 6, 2023, at the Diagnosis Related 
Group (DRG) originally billed.