August 15, 2015

Helpful Hospital
HIC # 0000312
MRN: 7762294
Patient Name: Doe, Jane
Dates of service: 02/10/2012-02/14/2012
RAC Reference ID: 012345

To Whom It May Concern:

Helpful Hospital was notified by the RAC that it received claim that reveals a billing
pattern that is potentially inconsistent with one or more of the following: IOM,PIM,
DRG validation review, ICD-9-CM (for dates and services on claim); ICD-9-CM
Addendums and Coding Clinics, UHDDS for the above referenced claim. We are
writing to request redetermination of the RAC Decision which states:

She was determined to have decompensated CHF. It is noted that the attending
physician documented questionable pneumonia in the discharge summary.
However, the secondary diagnosis of 486 (pneumonia, organism unspecified) was
not supported by the clinical evidence in the medical record. Therefore code 486
has been removed from the claim. This change results in a reassignment of the
MS-DRG from 291 (heart failure & Shock w/ MCC) to 292 (Heart failure & Shock w/
CC)
The diagnosis of Pneumonia (486) for the patient listed above was stated by the
physician as questionable pneumonia due to the patient having a history of heart
failure and suffering from atrial fibrillation, CHF, Hyperlipidemia, Pulmonary
Hypertension, Hypercholesterolemia and pleural effusion. Upon admission on
February 12, 2012 the patient presented respiratory distress, confusion, diminished
basilar crackles in bilateral lungs, no use of accessory muscles for breathing, chest
elevated AP diameter and 2-3+ bilateral edema. Due to the patients presentation
the physician ordered a chest x-ray that showed atelectasis and tiny bilateral
pleural effusion. Although the pneumonia was charted as questionable, the
physician had reason to believe it could be present due to the major complications
of heart failure that the patient was experiencing. The patient was also prescribed
antibiotics (Vancomycin which was discontinued and then Omnicef) for the
pneumonia. The diagnosis was then followed up with a chest X-ray that confirmed
that pneumonia was not present.
According to the ICD-9, it specifies that the etiology (primary) is followed by the
manifestation (secondary). This means that certain conditions have both an
underlying etiology and multiple body system manifestation due to the underlying
etiology. The physician used the term possibly to indicate that further diagnostic
evidence must be obtained to rule out other possibilities. The diagnosis and
treatment corresponded with the diagnostic workup; therefore this claim should be
approved.
Helpful Hospital has developed process and procedures for determining the
clinically appropriate level of care. The process is based upon established clinical
criteria, community standards of care, payer-specific guidelines and an internal
clinical review process. A rigorous utilization assessment is conducted on all
admissions and each case is validated for the appropriateness of the level of care
assigned. Helpful Hospital is confident that we have billed this correctly and in
compliance with Medicare and other Federal laws which are presented in this
appeal. We request that diagnosis of 486 (Pneumonia) be added back to the claim
and the MS-DRG 292 (Heart Failure & Shock w/ CC) be changed back to MS-DRG 291
(Heart Failure & Shock w/ MCC)

Sincerely,

Team 1 Lavatus Windom & Michele Hornick