OIG: Physicians Generally Miscode POS

An Office of Inspector General (OIG) review suggests physicians correctly code the place of service (POS) in Medicare Part B claims only 10 percent of the time. This pattern of incorrectly coded claims for nonfacility services resulted in Medicare overpaying physicians an estimated $13.8 million in 2007, the OIG concludes in a July report.

Of the 100 services the OIG sampled, 90 of the services were coded as having been performed in a nonfacility location, when 60 of the services were actually performed in hospital outpatient departments and 30 were performed in ambulatory surgical centers (ASCs).

Ambulatory Surgical Center CASCC

The OIG provides in the report this example of incorrect coding:

“A carrier paid a physician $374 for performing a spinal pain injection procedure coded as having been performed in his office. Our analysis showed that the physician actually performed this procedure in a hospital outpatient department and that a fiscal intermediary had reimbursed the hospital for the overhead portion of the service. If the claim had been coded correctly, the physician would have received a payment of $96, which would not have included overhead costs. As a result of the incorrect coding, the physician was overpaid $278.”

The OIG report recommends for the Centers for Medicare & Medicaid Services (CMS) to immediately reopen the claims associated with the 484,118 nonsampled services and work with the physicians who provided the services (and more than likely miscoded the POS) to recover any overpayments.

For complete details, read the OIG July 2010 report; and for POS codes and definitions, refer to CMS Pub. 100-04, Medicare Claims Processing Manual, chapter 26, section 10.5.


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4 Responses to “OIG: Physicians Generally Miscode POS”

  1. Joan says:

    I’d strongly suggest reading the details of the OIG’s report yourself. Despite what this article states, the OIG did NOT conclude that physicians correctly code the place of service (POS) in Medicare Part B claims only 10 percent of the time.

    If you look at the study design itself, the only claims that the OIG considered in their universe of claims to be reviewed were claims for services provided in the outpatient facility setting (hospital outpatient or ASC) where both the physician and the facility reported the same procedure (CPT code) for the same date of service.

    The OIG did not look at any claims for services provided in the office setting. It didn’t look at any services provided in the inpatient or nursing home setting. It didn’t look at any claims where the physician was only reporting an E/M service (since the physician and facility would likely not use the same CPT code in those cases). It **ONLY** looked at ASC and hospital outpatient claims — and then only for those where there was a match on the codes for that date of service.

    Accordingly, the conclusion of the study (regarding the 90% error rate on POS code selection) absolutely cannot be generalized to the assignment of POS codes to ALL physician claims, as the EDGE BLAST synopsis of the study erronously presumes. It is only applicable to that extremely limited set of circumstances (procedures performed in the hospital outpatient and ASC setting).

    If your practice performs procedures in those settings, then yes, you should do an internal audit to make sure that POS 22 or POS 24, not POS 11, should be reported when the procedure is performed in those facility settings. THAT is the problem area – not the entire listing of claims a physician submits.

  2. Dawn Madsen says:

    I strongly agree with Joans comment about this study and knew that there must have been something not quite accurate about this conclusion. Thank you for pointing this out!

  3. Melanie says:

    Thank you for clarifying the article. I too thought something wasn’t right about this and knew there had to be a further explanation. We just aren’t all that incompetent.

  4. renee says:

    As the author of this article, I’d like to thank Joan for her accurate clarification of this article.

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