Can hospitals receive full inpatient admission reimbursement for a patient experiencing diabetic ketoacidosis who only spends one night in the hospital? AppriseMD’s latest case study shows that it is possible. A young adult patient with type 1 diabetes struggling with consistent vomiting over two weeks stayed one night as a hospital inpatient, but commercial insurance denied the stay. This straightforward case demonstrates the value of consistently engaging the payers in peer-to-peer discussions with skilled physician advisors to ensure appropriate reimbursement.
CLINICAL SUMMARY:
A 26-year-old patient with type 1 diabetes arrived at the Emergency Department nauseated and vomiting. The vomiting began about two weeks prior and worsened the day the patient decided to go to the hospital because he could not keep down food or liquids. Doctors determined the patient had diabetic ketoacidosis (DKA). The patient continued taking insulin as usual and reported keeping a close watch on his sugar levels despite long 12-hour work shifts.
Upon entering the ED, the patient was afebrile and tachycardic with a heart rate of 110, normal respiratory rate, normal oxygen saturation and blood pressure. Blood work was consistent with DKA and showed glucose 420, ketones positive in both blood and urine, anion gap 23, CO2 19, and Osm 307. Labs showed EtOH negative, essentially normal electrolytes except magnesium low at 1.5, liver functions mostly normal but T. bili 1.5, and urine drug test positive for cannabinoids. Labs upon admission showed a pH of 7.3 and a beta-hydroxybutyrate of 5.4. The patient’s A1c repeated in the ED was 12.9%
Admitted at the inpatient level of care (LOC) for treatment with an insulin drip and DKA protocol, the patient’s DKA resolved quickly within 12 hours of admission. After transitioning off the insulin drip and on to glargine 25 units, however, the patient had borderline hypoglycemia. The patient was discharged after turning down a meeting with a nurse diabetes educator, stating that he had an outpatient diabetes educator appointment scheduled.
INPATIENT STAY DENIAL
The patient’s commercial insurance carrier denied the inpatient level of care after evaluating the patient’s clinical records in tandem with MCG’s inpatient policy for diabetes. The carrier agreed that the patient was vomiting and found to be in diabetic ketoacidosis, but stated that the IV insulin was able to resolve the DKA within the observation LOC. The denial letter also included the fact that the patient was discharged the next day.
THE APPRISEMD METHOD
An AppriseMD physician advisor conducted a peer-to-peer discussion with the insurance company’s medical director to discuss the details of the case. The patient, who presented with diabetic ketoacidosis, had a pH level of 7.3 in addition to a beta hydroxybutyrate of 5.4. Doctors treated the patient with DKA protocol and discharged him once blood sugars and pH levels improved. The physician advisor also pointed out that the presence of DKA with two weeks of vomiting supported the medical necessity for inpatient LOC, which the carrier medical director agreed with. This resulted in the denial being overturned despite the short length of stay.