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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Medicare Part B Mutually Exclusive Procedure Codes at Hospital Outpatient Departments," (A-01-98-00507)

May 17, 1999

Complete Text of Report is available in PDF format (1.34 MB). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


The Health Care Financing Administration (HCFA) requires Medicare carriers to establish edits to preclude payment for certain mutually exclusive radiology and pathology/laboratory services provided in doctors' offices and clinics. The HCFA could obtain significant savings (approximately $29.1 million over a 2 year period) if similar edits were required for such services provided in hospital outpatient departments. We recommended that HCFA instruct fiscal intermediaries to implement such edits and notify hospital providers that Medicare Part B will no longer pay for mutually exclusive procedures codes related to radiology and pathology/laboratory services. The HCFA concurred with our recommendations.