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Review of Medicare Part B Mutually Exclusive Procedure Codes at Hospital Outpatient Departments

Issued on  | Posted on  | Report number: A-01-98-00507

Report Materials

EXECUTIVE SUMMARY:

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.

Report Type
Audit
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
-
Target Groups
-
Financial Groups
-

Notice

This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.