OIG Questions Ultrasound Claims

The rapid increase of ultrasound services nationwide has Medicare watchdogs on the alert. Health care practitioners who submit Part B claims for technical and professional ultrasound services can expect added scrutiny. A recent Office of Inspector General (OIG) report provides insight as to what Medicare Administrative Contractors (MACs) will soon be on the lookout for when reviewing imaging service claims.

The OIG conducted an analysis of Medicare Part B claims for ultrasound services to determine the use of such services in high-use counties compared to other counties and to identify claims with questionable characteristics.

In 2007, the OIG found high-use areas to include several counties in Florida, New Jersey, and New York, and one county in Texas and Alabama. According to the OIG report, 42 percent of the beneficiary populations in Miami-Dade, Fla. and Charlotte, Fla. received ultrasound services that year.

The OIG also found that one in five ultrasound claims sampled nationwide had characteristics that raised concerns about whether they were appropriate.

In reviewing sampled claims, the OIG considered the following five characteristics as questionable (for investigational purposes only):

  1. Lack of a service claim by the ordering doctor for treating the beneficiary (most common).
  2. Questionable use of ultrasound billing codes, such as suspect combinations of ultrasound services billed for the same beneficiary on the same day by the same provider or specific procedures that aren’t effective in adults.
  3. Five ultrasound services provided to the same beneficiary on the same day by the same provider.
  4. Beneficiaries who had ultrasound services billed for them by more than five providers.
  5. Missing or invalid data in the claim fields that identify the ordering doctor.

Ultrasound procedure codes the OIG found most often involved in claims with questionable characteristics are:

    • 76700    Ultrasound, abdominal, real time with image documentation; complete
    • 76705    Ultrasound, abdominal, real time with image documentation; limited (eg, single organ,  quadrant, follow-up)
    • 76830    Ultrasound, transvaginal
    • 76856    Ultrasound, pelvic (nonobstetric), real time with image documentation; complete
    • 93925    Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
    • 93978    Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

Medicare covers ultrasound as a diagnostic service and divides imaging services into two components: the technical component (TC) and the professional component (PC). The TC (the certified imaging technician) is paid under Medicare Part B when the service is performed in an ambulatory surgery center (ASC) or independent lab. The PC is the physician who interprets the ultrasound and is always paid under Part B regardless of where the service is performed.

The OIG recommends in the report for the Centers for Medicare & Medicaid Services (CMS) to monitor ultrasound claims data to detect questionable claims and take action when providers bill for high numbers of questionable claims for ultrasound services. CMS concurred and said it will share the OIG’s findings with MACs for potential additional prepay edits and prepay medical review, and forward questionable claims identified in the OIG report to its Recovery Audit Contractors (RACs).

For more information, read the full report “Medicare Part B Billing for Ultrasound,” posted July 10 on the OIG Web site.

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3 Responses to “OIG Questions Ultrasound Claims”

  1. Robert E. Markle says:

    Not as bad but almost as bad as the 70’s when every other women got a hysterectomy.

  2. JOYCE D EVERETT says:

    I agree with the need to police the ultrasound billing not only from a medical necessity but also the quality and accuracy of the studies. As a specialist we often see inaccurate reports because of technical quality as well as poor quality of the study. We must then either redo the ultrasound or do a CTA to determine true vessel disease.

  3. Terry J. Haney says:

    This issue has emerged over on the commerical side as some insurance companies are now managing (preauthorization) of OB ultrasound. Some state Medicaid commissioners are looking closely at ultrasound services as well. It only takes a few ‘over-utilizers’ to bring down the scrutiny upon everybody!

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