BACKGROUND
The Social Security Act and Centers for Medicare & Medicaid Services (CMS) regulations govern Medicare payments for all radiology services and require that services be medically necessary, have documentation to support the claims, and be ordered by physicians.
We used the 2008 National Claims History File to identify 9.6 million Medicare claims ($215 million) for interpretation and reports of diagnostic radiology services for beneficiaries in hospital outpatient emergency departments. Our review consisted of two simple random samples of claims: a sample of 220 CT and MRI claims and a sample of 220 x-ray claims. We used a document review instrument to review all medical record documentation requested from facilities for each sampled claim. We considered sampled claims erroneous if (1) documentation did not support that services were performed or (2) physicians’ orders were not present. We also reviewed all interpretation and reports to determine whether they were performed during beneficiaries’ diagnoses and treatments in hospital outpatient emergency departments. Finally, we reviewed interpretation and reports for all sampled claims for consistency with the American College of Radiology’s suggested documentation practice guidelines.
FINDINGS
In 2008, Medicare claims for interpretation and reports of 19 percent of CTs and MRIs and 14 percent of x-rays in hospital outpatient emergency departments were erroneous because of insufficient documentation. Of the nearly 3 million claims allowed for interpretation and reports of CT and MRI services in hospital outpatient emergency departments in 2008, Medicare erroneously allowed 19 percent, amounting to nearly $29 million. Of the nearly 6.6 million claims allowed for interpretation and reports of x-ray services in hospital outpatient emergency departments in 2008, Medicare erroneously allowed 14 percent, amounting to nearly $9 million. Physicians’ orders were not present in medical record documentation for 12 percent of CT and MRI interpretation and report claims, amounting to nearly $18 million. Physicians’ orders were not present in medical record documentation for 9 percent of x-ray interpretation and report claims, amounting to $5 million. Documentation was not provided to support that interpretation and reports had been performed for 12 percent of CT and MRI claims, amounting to nearly $19 million, and 8 percent of x-ray claims, amounting to $5 million.
In 2008, Medicare paid for interpretation and reports performed for 16 percent of x-rays and 12 percent of CTs and MRIs after beneficiaries left hospital outpatient emergency departments; CMS offers inconsistent payment guidance on the timing for interpretation. CMS’s guidance to contractors states that contractors are to pay only for the interpretation performed “at the same time” as the diagnosis and treatment of the beneficiary in the emergency room if contractors receive multiple claims from, for example, the emergency room physician and the radiologist. However, contractors are not required to confirm that the interpretation was performed while the beneficiary was in the emergency department if only one claim is received. Medicare allowed more than $10 million (16 percent of claims) for interpretation and reports of x-rays that were performed after beneficiaries left hospital outpatient emergency departments and, based on OIG’s prior work in this area, may not have contributed to beneficiaries’ diagnoses and treatments. Of the $10 million, $7.5 million was for claims that had physicians’ orders and documentation to show that interpretation and reports had been performed. In addition, Medicare allowed $19 million for interpretation and reports of CTs and MRIs that were performed after beneficiaries left hospital outpatient emergency departments. Of the $19 million, $5.4 million was for claims that had physicians’ orders and documentation to show that interpretation and reports were performed.
Interpretation and reports for 71 percent of x-rays and 69 percent of CTs and MRIs in hospital outpatient emergency departments did not follow one or more suggested documentation practice guidelines promoted by the American College of Radiology. Seventy-one percent of interpretation and reports for x-rays did not follow one or more suggested practice guidelines. Sixty-nine percent of interpretation and reports for CTs and MRIs did not follow one or more suggested practice guidelines. Documentation standards for interpretation and reports are essential for determining whether diagnostic radiology services contribute to beneficiaries’ diagnoses and treatments.
RECOMMENDATIONS
We recommend that CMS:
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 noncontemporaneous interpretations may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments. Take appropriate action on the erroneously allowed claims identified in our sample.
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE
In its written comments on the report, CMS concurred with the first and third recommendations. CMS did not concur with the second recommendation. In response to the first recommendation, CMS indicated that it will issue an educational article to the provider community to emphasize that documentation requirements will be enforced. In response to the third recommendation, CMS indicated that upon receipt of the files from the Office of Inspector General, it will take appropriate action. CMS will instruct the Medicare Administrative Contractors to consider this issue when prioritizing their medical review strategies or other interventions.
In response to the second recommendation, CMS indicated 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. A uniform policy requiring that interpretation and reports be contemporaneous with, or, if not contemporaneous, demonstrably contribute to the beneficiary’s diagnosis and treatment could reduce unexplained complexity in what is already a complicated billing system for medical diagnostics. We have revised the language of the second recommendation to clarify what we are recommending.
