Vulnerabilities Exist Related to Hospitals' Billing of Drugs Different From Those That May Have Been Administered to Medicare Enrollees

OBJECTIVE

Medicare requires hospitals to submit accurate claims for outpatient services, including drugs administered. Hospitals must use standardized codes, called Healthcare Common Procedure Coding System (HCPCS) codes, for drugs administered. Most National Drug Codes (NDCs), which are unique numbers used to identify drugs in the United States, are assigned to HCPCS codes. Hospitals may be billing for administered drugs using an HCPCS code different from the one assigned to the NDC reported on the claim. This means that they may be billing for drugs that were not the ones administered. We will identify ways in which Medicare is potentially vulnerable to improper payments when hospitals bill for drugs with HCPCS codes that do not match those assigned to the NDCs listed on the claims.

TIMELINE

• June 17, 2025
  Announced
• Today
  Office of Audit Services In-Progress
• Est FY2027
  Estimated Fiscal Year for Project Completion

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