What the provider receives

A determination that says only “unsupported” cannot be answered: the provider cannot tell which question was decided, so the appeal addresses the wrong one and the reviewer has nothing to audit. This letter separates the three questions, numbers them, and says what would overturn each.

Back to the audit Reasoning trace

Drafted by Autonomize · not sent

Overpayment notice — St. Bernard Regional Medical Center

$2,956.64

Re: claim CLM-0000013 · member MBR-77031482 · admission 12 March 2026

A post-payment review of the claim above identified $2,956.64 as recoverable. The review separates three questions, and each is answered in its own numbered section below. Each section can be disputed on its own; disputing one does not put the others in issue.

Policy basis

This review applied each policy as it stood on 12 Mar 2026, the date of service, not as it stands today. No policy cited below has changed since then, so the current version and the governing version are the same document.

1 Coding Was the service coded according to the coding rule? Finding

Billed DRG 291 · heart failure with MCC. Severity up-coding. A single unsubstantiated MCC moved the admission up a severity tier and took the payment with it.

Remedy: Reprice to DRG 292.

CPP-047 v3.1 Inpatient DRG validation — complications and comorbidities

To dispute section 1 Cite the coding rule or payer guidance under which DRG 291 · heart failure with MCC is correct on this record, or submit a corrected claim at the level the record supports.

2 Clinical documentation Does the record support the service that was coded? Finding

DRG 291 rests on an MCC the record does not support. N17.9 acute kidney failure was coded as the major complication that lifts this admission from DRG 292 to 291. Peak creatinine was 1.1 mg/dL against a 1.0 baseline with normal urine output — no KDIGO stage is met at any point of the stay. Without the MCC the admission groups to DRG 292.

CPP-047 v3.1 Inpatient DRG validation — complications and comorbidities

To dispute section 2 Submit the part of the medical record for 12 Mar 2026 that documents what the billed code requires. The review was conducted on the documentation submitted with the claim; anything not sent with it was not seen.

3 Payment What, if anything, is recoverable? Finding

Weight difference of 0.4348 at a $6,800.00 base rate. DRG 291 weight 1.2838 paid $8,729.84. DRG 292 weight 0.8490 pays $5,773.20. The recoverable difference is $2,956.64.

Line	Code	Paid	Allowable	Recoverable
1	DRG 291 1 × per service	$8,729.84	$5,773.20	$2,956.64

Priced against

MS-DRG 291 carries a relative weight of 1.2838 and MS-DRG 292 a weight of 0.8490, a difference of 0.4348. CMS MS-DRG v43

The 4-day stay is consistent with the DRG 292 arithmetic mean length of stay of 3.7 days. CMS MS-DRG v43 length-of-stay tables

To dispute section 3 Show that the allowable applied here is the wrong one — wrong site of service, wrong locality, or wrong fee schedule year. The arithmetic above is shown in full so it can be checked directly.

Your rights

You may dispute any section on its own. Name the section number and send what that section asks for; the other sections are unaffected.
Submit a dispute within 30 days of the date of this notice and payment activity is held pending review.
You may instead remit the amount above within 30 days, or notify us in writing that you elect offset against future payments.

Payment Integrity · 1-800-000-0000 · recoveries@example.org

What the agent did not do

Said on the letter itself, not only here. The case for putting an agent this close to a recovery rests on where it stops.

This letter was drafted by the review and has not been sent.
No recoupment has been taken and no offset has been applied.
No provider record was corrected and no authorization was changed.
A named reviewer signs, or does not.

Every figure is derived

The addressing — who it is to, which claim, the phone number — comes from the audit book. Everything that asserts something is computed from the claim when the page is built: the amount is the sum of the line variances, the sections are the finding's own layers, and the policy version is resolved at the date of service. A seeded sentence can drift from the claim it describes. This cannot.

Sections in dispute

Each is answered separately. A provider who disputes one does not put the others in issue, and the analyzer routes their argument to the section it actually contests.

1 Coding

separately appealable

2 Clinical documentation

separately appealable

3 Payment

separately appealable

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