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Originally Posted by golfing eagles
Sorry, but wrong. What was described isn't far off for procedures like an MRI, where there is in fact a technical and professional component. But that in no way applies to the E&M codes used in primary care and other specialties. Furthermore , those E&M codes apply to billing for traditional Medicare, but not for Medicare Advantage Plans which are capitated. Please don't contribute to the plethora of misinformation already floating around this site.
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The wording below by Luria is vague enough "did not appear to be supported by a sufficiently documented clinical basis" that this could be more about a lack of documentation than incorrect entries. We won't know until there are more details presented. I also wonder how much this has to do with the changes made in 2018, 2021, etc. regarding documentation and whether the entire staff kept up with the changes. I know from nearly 40 years in radiation oncology there are more than a small number of people that have different options on coding matters.
Outpatient E/M Coding Simplified | AAFP
Lastly, in the physician groups I've worked with, they not only selected the ICD code, but they also itemized the codes that would be charged (both for pre-auth and giving the patient their good faith estimates for care) as well as dictated the documentation justifying all charges.
"TVH Chief Restructuring Officer Neil Luria said in a July 3 court filing that last year the company hired outside law firms and FTI Consulting Inc. to evaluate the accuracy of the health-care provider’s coding and to investigate any potential over-payments related to Medicare.
That investigation “identified codes TVH submitted that did not appear to be supported by a sufficiently documented clinical basis,” Luria said. The inquiry also identified amendments to patient medical records “appear to have been inconsistent with [the Centers for Medicare and Medicaid Services] guidance and based on a misunderstanding of the relevant guidance on medical record amendments, including when it is appropriate to amend a patient record more than 90 days after an encounter,” he said."