E/M Coding Alert - 2015 Issue 20
Compliance: OIG: Just 6 Line Items Caused $1.7 Million Overbilling
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Article Overview
This article discusses an OIG audit involving billing errors for a drug used in eye care, the resulting overpayments, and the broader compliance risks tied to HCPCS code assignment for drugs and biologicals. It is aimed at coders, billing staff, compliance teams, and providers who handle Medicare claims and want to understand why payer verification, diagnosis alignment, and payment review matter.
Why This Topic Matters
The article highlights how a small number of incorrect line items can create major overpayment liability and trigger payer scrutiny, refunds, and compliance risk.
What You Will Learn
- Why accurate HCPCS code assignment is especially important for drug and biological claims
- How billing and diagnosis mismatches can contribute to audit findings
- Why unusually high payment amounts should prompt internal review
- How payer verification contacts can affect claim processing and compliance risk
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Physicians and practice managers
- Revenue cycle teams
Codes Discussed
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