Emergency Department Procedure Codes Audit Findings

This report details an audit conducted by the Office of Inspector General (OIG) regarding the use of emergency department procedure codes on Medicare claims for services billed from nonemergency department sites. The objective of the audit was to assess whether the Centers for Medicare & Medicaid Services (CMS) ensured compliance with Medicare requirements for these claims. The findings indicate that CMS failed to enforce compliance, resulting in over $15 million in improper and potentially improper payments. Specifically, the audit revealed that physicians improperly billed for 9,749 procedures totaling $922,524, while hospitals received $14.2 million in potentially improper payments. The report outlines the lack of adequate claims processing controls and guidance from CMS, which contributed to these issues. Five recommendations were made to CMS, including recovering improper payments and improving billing guidance. CMS concurred with one recommendation but did not agree with the others, highlighting ongoing challenges in ensuring compliance with Medicare billing requirements.