Emergency Department Procedure Codes Used on Medicare Claims for Services Billed With Nonemergency Department Site of Service or Revenue Center Codes Resulted in Millions in Improper and Potentially Improper Payments

OBJECTIVE

An emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Certain Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes should be used only if a Medicare enrollee is seen in the emergency department and the services described by the codes' definitions are provided. Medicare reimburses providers based on the patient's documented service needs at the time of the visit and based on the site of service. This audit will determine whether Medicare appropriately paid hospitals and physicians for emergency department services provided in nonemergency department sites of service.

TIMELINE

• September 11, 2023
  Announced
• Today
  Office of Audit Services In-Progress
• Est FY2026
  Estimated Fiscal Year for Project Completion

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