Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 25, 2022, to 
March 7, 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 the 
claim should be paid. The Plan denied your request. The Plan says the secondary diagnosis code of J96.01 and 
J96.02 have been removed from the claim consisted with documentation received. The Plan states they main 
their initial findings and uphold the change from DRG 064 to DRG 065. 
 
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 J96.01-acute respiratory failure with hypoxia and 
J96.02 - acute 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 physician reviewer found that for diagnosis code J96.01 -acute respiratory failure with 
hypoxia - Documentation submitted was reviewed and does not meet criteria. The medical record includes 
insufficient documentation to confirm acute respiratory failure with hypoxia. Medical record supports the 
enrollee was on a ventilator and consistently documents intubated for airway protection. Laboratory report 
documents venous blood gas pH of 7.192 and pCO2 48.7, fluid management and antiseizure medication 
resulted in decreased lactic acid levels. Additional blood gasses remained stable. Invasive mechanical 
ventilation is an intervention that is frequently used in acutely ill patients requiring either respiratory support or 
airway protection. In this case, documentation does not support code reported. For diagnosis code J96.02 - 
acute respiratory failure with hypercapnia, the documentation submitted was reviewed and does not meet 
criteria. The medical record includes insufficient documentation to confirm acute respiratory failure with 
hypercapnia. The medical record supports patient was on a ventilator and consistently documents intubated for 
airway protection. Laboratory report documents venous blood gas pH of 7.192 and pCO2 48.7, fluid 
management and antiseizure medication resulted in decreased lactic acid levels. Additional blood gasses 
remained stable. Invasive mechanical ventilation is an intervention that is frequently used in acutely ill patients 
requiring either respiratory support or airway protection. In this case, the documentation does not support code 
reported  
 
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 February 25, 2022, to March 7, 2022, at the Diagnosis Related 
Group (DRG) originally billed.