Knowledge Base Article

Did You Know?

Livanta, the National Medicare Claim Review Contractor, samples claims for review monthly for short stay reviews (SSRs) and higher weighted DRG (HWDRG) reviews. As part of their Provider Education efforts, they publish a monthly newsletter called The Livanta Claims Review Advisor.

The first Claims Review Advisor newsletter was published two years ago this month in February 2022. Livanta noted in that newsletter that it is meant “to share its review findings and provide guidance to healthcare organizations…each month’s content will highlight areas of interest for medical coders, billing professionals, clinical documentation improvement (CDI) professionals, physicians, and other practitioners.” Topics alternate between SSRs and HWDR reviews each month.

Why It Matters?

Livanta recently released the January 2024 edition of The Livanta Claims Review Advisor with a focus on SSRs for electrolyte abnormalities. You will find error rates by MS-DRG, example scenarios of specific electrolyte abnormalities (i.e., hyperglycemic emergencies), and guidance for documenting “the reasonableness of a two-midnight expectation at the time of inpatient admission: regardless of the MS-DRG.

Error Rates

Overall, Livanta completed 1,985 reviews for dates of service from October 2021 through December 2023 for the following MS-DRGs:

• MS-DRG 637: Diabetes with MCC,
• MS-DRG 638: Diabetes with CC,
• MS-DRG 639: Diabetes without CC/MCC,
• MS-DRG 640: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes with MCC (error rate 10.20%), and
• MS-DRG 641: Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes without MCC.

MS-DRG 641 had the highest reported error rate at 11.60%.

How Big is the Pool of Claims?

Based on claims data provided by our sister company RealTime Medicare Data (RTMD), in the CMS FY 2023 (October 1, 2022 through September 30, 2023) for all fifty states and Washington D.C. combined, there were 73,497 claims that grouped to one of the above MS-DRGs. The total payment made to providers for this group of claims was $481,535,832.43.

Note, claims with a discharge disposition of expired (20), transfer to another acute care facility (02), transfer to a short-term general hospital with planned acute hospital inpatient readmission (82), left against medical advice (07), and hospice election (50 & 51) have been excluded from this data as CMS considers these to be “unforeseen circumstances.” I have included MS-DRG specific claims data in the table at the end of this article.

What Can You Do?

• Read the January 2024 of The Livanta Claims Review Advisor and share with key stakeholders at your facility.
• Review a sample of short stay claims to determine if documentation supported the inpatient admission or if care could have been provided on an outpatient basis.
• View past editions of this newsletter at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html, and
• If you have not signed up to received Livanta’s publications, I encourage you to do so at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/bulletin.html.

Resources

Change Request CR10080 and related MLN MM10080: Clarifying Medical Review of Hospital Claims for Part A Payment