Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided from January 23, 2023, through 
January 26, 2023, at the DRG calculated with the inclusion of J96.21 as a secondary diagnosis code. We 
decided that the Plan does not have to pay for the inpatient hospital services provided from January 23, 2023, 
through January 26, 2023, at the Diagnosis Related Group (DRG) originally billed.  
 
You asked the Plan to pay for the inpatient hospital services provided from January 23, 2023, through January 
26, 2023, at the Diagnosis Related Group (DRG) originally billed. You say that secondary diagnosis codes 
J96.21 and J96.22 are supported in the documentation, therefore the claim should be paid at the original DRG. 
The Plan says that diagnosis codes J96.21 and J96.22 are not supported in the documentation. 
 
We decided that the Plan has to pay for the inpatient hospital services provided from January 23, 2023, 
through January 26, 2023, at the DRG calculated with the inclusion of J96.21 as a secondary diagnosis 
code. 
 
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 secondary diagnosis codes J96.21, defined as acute 
and chronic respiratory failure with hypoxia, and J96.22, defined as acute and chronic respiratory failure with 
hypercapnia. 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 secondary diagnosis code J96.21 is supported in the 
documentation, but secondary diagnosis code J96.22 is not supported in the documentation. Our physician 
reviewer found J96.21 is supported with pneumonia and documented hypoxia, but J96.22 is not supported as 
the enrollees carbon dioxide levels were documented to be normal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG calculated with the inclusion of J96.21 as a secondary diagnosis code. 
Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from January 23, 
2023, through January 26, 2023, at the DRG calculated with the inclusion of J96.21 as a secondary diagnosis 
code. 
 
We also decided that the Plan does not have to pay for the inpatient hospital services provided from 
January 23, 2023, through January 26, 2023, at the Diagnosis Related Group (DRG) originally billed.  
 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. 
 
As noted in the medical review above, our physician reviewer found that secondary diagnosis code J96.22 is 
not supported in the 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 originally billed. Therefore, we decided that the Plan does not 
have to pay for the inpatient hospital services provided from January 23, 2023, through January 26, 2023, at the 
Diagnosis Related Group (DRG) originally billed. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.