CMS Improperly Paid $38M for ED Outpatient Imaging, OIG Says

The Centers for Medicare & Medicaid Services' "inconsistent payment guidance" erroneously allowed about $38 million for improperly documented imaging claims in hospital outpatient emergency departments in 2008, a Department of Health and Human Services Office of Inspector General audit has determined.

A breakdown of the erroneous payments included 19% of claims -- with a value of $29 million -- for interpretation and reports for computed tomography and magnetic resonance imaging and 14% of claims -- valued at $9 million -- for interpretation and reports for X?rays, the OIG audit found.

Of the allowed Medicare claims for CTs and MRIs in hospital outpatient EDs in 2008, the OIG audit found that:

• 12% ($18 million) did not have physicians' orders as part of the medical record
• 12% ($19 million) did not have documentation to support that interpretation had been performed
• 5% ($7.3 million) had overlapping errors

Of the allowed Medicare claims for X-rays in hospital outpatient EDs in 2008, the OIG audit found that

• 8.6% ($5.5 million) did not have physicians' orders as part of the medical record
• 8.2% ($5.4 million) did not have documentation to support that interpretation had been performed
• 3% ($1.9 million) of claims had overlapping errors

The audit also found that 12% ($19 million) of CT and MRI claims and 16% ($10 million) of X-ray claims were for interpretation and reports that, while not erroneous, were performed after beneficiaries left EDs, OIG said. 

OIG blamed the overpayments on what it said was CMS' "inconsistent payment guidance on the timing for interpretation. In 2008, 71% of interpretation and reports for X?rays and 69% of interpretation and reports for CTs and MRIs did not follow one or more of the American College of Radiology-suggested documentation guidelines." 

• Educate providers on the requirement to maintain documentation on submitted claims,
• Adopt a uniform policy for single and multiple claims for interpretation and reports of diagnostic radiology services to require that claimed services be contemporaneous or identify circumstances in which non-contemporaneous interpretations may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments

In its written response, CMS disagreed with the call to adopt a uniform policy for single and multiple claims, saying that it does not believe that a single billed interpretation must in all cases be contemporaneous with the beneficiary's diagnosis and treatment to contribute to that diagnosis and treatment.

However, OIG said a uniform policy requiring that the interpretation and report be contemporaneous with or contribute to the beneficiary's diagnosis and treatment could reduce unexplained complexity in what is already a complicated billing system for medical diagnostics.