A commercial health insurance payer conveying their determination that a patient’s inpatient admission has been denied as submitted.

You receive a letter, dated 09/19/2020, from a commercial health insurance payer conveying their determination that a patient’s inpatient admission has been denied as submitted. The payer has revised the MS-DRG to a lower paying MS-DRG, stating that the secondary diagnosis is not valid and relevant to the admission. Key points from the denial letter include:

Patient Name: Amy Green DOB:  01/28/1934

Member #: B3456700, Claim #: 820550710106

DOS: 07/20/2020 – 07/23/2020

Denial of MS-DRG 187 with revision to MS-DRG 188

Reason for the denial: secondary diagnosis of E87.1 (hyponatremia) not validated as relevant to this admission. The patient did not meet guidelines to qualify for MS-DRG 187 with Hyponatremia as a secondary diagnosis.

Clinical references provided for a diagnosis of hyponatremia:

Definition: hyponatremia is usually defined as plasma sodium of less than 135 meq/L

Moderate severity = serum sodium between 121-129 meq/L

Mild severity = serum sodium between 130-135meq/L

Symptoms of hyponatremia include: Confusion, Fatigue, Headache, Irritability, Loss of appetite, Muscle spasms, weakness or cramps, Nausea and/or vomiting and restlessness

Treatments may include Intravenous fluids, Medications (e.g. loop diuretics)

Contractual guidelines to qualify for coverage of hyponatremia require clinical documentation of mild to moderate severity at a minimum.

You perform a detailed review of the entire health record and review the ICD-10-CM Official Guidelines for Coding and Reporting and determine that hyponatremia, code E87.1, is coded accurately and is supported in the health record. The following key points from the health record support your position:

Admission history and physical includes patient complaints of: crampy abdominal pain, diarrhea, decreased appetite, weakness

The patient presented on 07/20/2020 with a sodium level of 127 meg/L

Subsequent sodium levels were: 130 meq/L on 07/21/2020 at 0800; 131 meq/L on 07/21/2020 at 1930; 132 meq/L on 07/22/2020 at 0730; 133 on 07/22/2020 at 2130

Patient received intravenous fluids and IV Lasix

Based on the above information, draft up a mock “appeal letter” to support the position that the diagnosis of hyponatremia is supported and the final MS-DRG of 187 is accurate.