On March 28, 2014, the US Department of Health and Human Services Office of Inspector General (“OIG”) issued a report identifying certain coding errors associated with hospital outpatient clinic visits in 2010 and 2011. The report, entitled CMS did not Always Correctly Make Clinic Visit Payments to Hospitals (A-04-12-06154), noted that “Medicare payments to hospitals for evaluation and management (E/M) outpatient clinic visits vary on the basis of whether patients are new or established.” OIG found that the vast majority of CMS outpatient clinic payments to hospitals were associated with claims that incorrectly identified established patients as new patients, included incorrect clinic level codes, or had other deficiencies. “Of the 110 randomly sampled line items for which CMS made Medicare payments to hospitals for clinic visits . . . during our audit period, 2 were correct.”OIG recited CMS informal guidance instructing that the same patient could be new to the physician but established at the hospital.

In addition to recommending that CMS reconcile the overpayments identified in its audit, OIG recommended that CMS resolve the 378,376 outstanding claims identifying hospital clinic services provided to new patients and “recover the overpayments to the extent feasible and allowed under the law.” A copy of OIG’s report is available here.

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