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Originally Posted by Rainger99
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I think this case goes way beyond that CMS "fact" sheet, but there is the 2 key conditions that result in overpayment: Wrong code and insufficient documentation. And that may be all there is to this, and then again, maybe not. But remember, the reviewers at CMS barely know how to spell medicine, much less have any knowledge of it. They are bean counters, pure and simple---does the progress note have 2 items from 6 different body systems in the exam or doesn't it? Are 2/3 items form past medical history, family history and social history included? That's all they know. Also, many EMRs look at what is included in the note and "suggest" a billing code. Could that be "off", did they coders at TVH just take the EMRs "suggestions".
Bottom line: This could still range anywhere from a computer EMR error and insufficient documentation to a conspiracy to commit criminal fraud. It's probably just aggressive coding like every other practice coupled with the CMS opinion that the documentation didn't meet their criteria, but time will tell. Unfortunately for TVH, this has become a complex high-profile case, and some bureaucrat is likely to act like a dog with a bone because they want to make a name for themselves so they can become a bigger bureaucrat.