Department of Health and Human Services
 
OFFICE OF 

 
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
MEDI CARE PART B  BILLING  

 
U  
FOR  LTRASOUND 

 
 
 
 
 
 
 
 
Daniel R. Levinson 
  
Inspector General 

 
July 2009 
 
OEI-01-08-00100 
    
 
 
Office of Inspector General

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components:  
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections  
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving  program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.    
   
  E X E C U T I V E   S U M M A R Y
OBJECTIVES 
To analyze Medicare Part B claims for ultrasound services to: 
1. 	  Describe utilization of ultrasound services in counties with high 
use of ultrasound and compare it to utilization in other counties.  
2. 	  Identify claims with questionable characteristics. 
BACKGROUND 
In 2007, Medicare Part B covered about 17 million ultrasound services 
in ambulatory settings at a cost of over $2 billion.  Previous Office of 
Inspector General work  has raised concerns about the growth in other 
types of imaging covered under Part B and found that high geographic 
concentrations of providers or services may indicate weaknesses in 
Medicares program safeguards. 
We used 2007 Medicare Part B claims data to identify 20 counties 
that were in the top 1 percent of counties for both average allowed 
charges for ultrasound per Medicare beneficiary and percentage of 
beneficiaries who received ultrasound services.  Nine of these counties  
were in Florida; five in New York; three in New Jersey; and one each  
in Alabama, Michigan, and Texas.  We analyzed the claims data to 
compare use of ultrasound in the high-use counties to that in all other 
counties.   We also examined claims for the presence of a limited set of 
questionable characteristics, such as suspect combinations of 
procedures or lack of a service claim from the doctor who ordered the  
service.  We did not assess the medical necessity  of services. 
FINDINGS 
In 2007, 20 high-use counties accounted for 16 percent of Part B 
spending on ultrasound despite having only  6 percent of Medicare 
beneficiaries.  The 20 high-use counties accounted for $336 million of  
the $2.1 billion in Part B spending on ultrasound services.  Average 
per-beneficiary spending on ultrasound in high-use counties was over 
three times  that for beneficiaries in the rest of the country.  Twice as 
many beneficiaries received ultrasound services in high-use counties as 
in the rest of the country.  When these beneficiaries received ultrasound  
services, they received more services  than other beneficiaries  receiving 
ultrasound services in the rest of the country.  Finally, the ratio of 
OEI-01-08-00100     PART  B  BILLING FOR  ULTRASOUND   i   
   
EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY    
ultrasound providers to beneficiaries in high-use counties was over 
three times  that for the rest of the country. 
Nearly one in five ultrasound claims nationwide had characteristics  
that raise concerns about whether the claims  were appropriate.   
These 3.2 million claims represent $403 million in Part B charges. The 
overall rate of ultrasound  claims exhibiting one or more questionable 
characteristics was the same in high-use counties as it was in all other 
counties.   Lack of a service claim by the ordering doctor for treating the 
beneficiary was the most common of  the questionable characteristics. 
The other characteristics were far less common but more prevalent in 
high-use counties than other counties. 
Certain providers billed for a large number of ultrasound claims with 
questionable characteristics. A group of 672 providers each billed 
500 or more claims with questionable characteristics. These providers 
collectively billed over half a million such claims representing over 
$81 million in Part B charges in 2007. 
RECOMMENDATIONS 
Given our findings, we recommend that the Centers for Medicare & 
Medicaid Services (CMS): 
Monitor ultrasound claims data to detect questionable claims.  This 
would reduce Medicares vulnerability to questionable claims for 
ultrasound services by enabling CMS to develop claims-processing edits 
that flag them for review prior to payment.  
Take action when providers bill for high numbers of questionable 
claims for ultrasound services. When its monitoring identifies 
providers that bill for large numbers of questionable claims, CMS should  
review their claims to ensure that they are legitimate prior to payment. 
If CMS determines that such providers submit fraudulent  claims, it 
should take steps to revoke their Medicare billing numbers.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
In its written comments to this report, CMS concurred with both of our  
recommendations and described actions it would take to address them. 
We did not make any changes to the report based on CMSs comments. 
OEI-01-08-00100     PART  B  B ILLING FOR  ULTRASOUND   ii   
   
  T A B L E   O F   C O N T E N T S  
 
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
  
 
 
 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
  
   
F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 
  
 
In 2007, 20 high-use counties accounted for 16 percent of 

 
Part B spending on ultrasound despite having only 6 percent of 

Medicare beneficiaries  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 
  
 
  Nearly one in five ultrasound claims nationwide had 

characteristics that raise concern about whether the 

  claims were appropriate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  8 
  
 
Certain providers billed for a large number of ultrasound claims 

with questionable characteristics. . . . . . . . . . . . . . . . . . . . . . . . . .  10 
  
 
   
R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11 
  
 
  Agency Comments and  Office of Inspector General Response . . .  11 

 
 
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13 
  
    A:  Data Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13 
  
 
  B:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 
  
 
 
A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18 
  
 
 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND      
   
I N T R O D U C T I O N  
  I N T R O D U C T I O N
 
OBJECTIVES 
To analyze Medicare Part B claims for ultrasound services to: 
1. 	  Describe utilization of ultrasound services in counties with high 
use of ultrasound and compare it to utilization in other counties.  
2. 	  Identify claims with questionable characteristics. 
BACKGROUND 
In 2007, Medicare spent over $2 billion for about 17 million ultrasound 
services in doctors offices, independent diagnostic testing facilities 
(IDTF), and other settings covered under Medicare Part B.  Previous  
Office of Inspector General (OIG) work has documented the growth in 
other types of imaging covered under Part B and raised concerns about  
the appropriateness of services.1  Previous OIG work has also found 
that high geographic concentrations  of providers  or services may 
indicate weaknesses in Medicares program safeguards.2  
Overview of Ultrasound Services 
Ultrasound imaging uses high-frequency sound waves to enable medical 
practitioners to view structures inside the body.  Ultrasound has 
numerous clinical applications, including diagnosing conditions in 
organs and  monitoring blood flow in veins and  arteries.  One example is  
echocardiography, which enables doctors to view and assess the 
pumping action of the heart. 
Ultrasound machines vary in size, imaging capabilities, and the parts of 
the body that they can examine.  Compared to other types of diagnostic 
imaging machines, which can cost millions of dollars to acquire and 
install, ultrasound machines are relatively inexpensive.  Providers can 
buy used machines for under $5,000 and roll them into examining 
rooms on carts. 
 
1 OIG, Growth in Advanced Imaging Covered Under the Medicare Physician Fee 
Schedule, OEI-01-06-00260, October 2007. 
2 OIG, South Florida Suppliers Compliance With Medicare Standards, 
OEI-03-07-00150, March 2007.  OIG, Aberrant Billing in South Florida for Beneficiaries 
With HIV/AIDS, OEI-09-07-00030, September 2007. 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   1   
   
II NN TT RR OO DD UU CC TT II OO NN    
Payment for Ultrasound Services Under Medicare Part B 
Medicare covers ultrasound as a diagnostic service under  1861(s)(3) 
of the Social Security Act. Medicare generally covers specified 
ultrasound procedures and will cover additional procedures if they are 
clinically effective and medically justified.3   
Medicare divides imaging services into two components: the technical 
component,  which is the taking of the image, and the professional 
component, which is the doctor interpreting the image. The technical 
component of ultrasound services provided in ambulatory settings, 
such as doctors offices and IDTFs, is covered under Part B.   The 
technical component of services provided in institutional settings, 
such as hospitals and hospital outpatient departments, is covered 
under Part  A. The professional component of ultrasound is always 
covered under Part B regardless of setting. 
METHODOLOGY 
Scope and Data Sources  
This study is national in scope and focuses on the technical component 
of fee-for-service ultrasound services billed under Part B in 2007. We 
focus on the technical component because it is the more costly 
component of ultrasound services and represents the best way to 
identify services that were provided entirely  in settings covered under 
Part B. Our data sources are Medicares 100-percent physician/supplier 
National Claims History (NCH) File  and the Denominator File from the 
Medicare Enrollment Data Base. We also consulted with a Medicare 
Program Safeguard Contractor (PSC).4   
Identification of High-Use Counties 
We first built a national file of all claims for the technical component of 
ultrasound services billed under Part B in 2007. To do so, we used 
Berenson-Eggers type of service groups in the range of I3A  through I3F  
as the criteria for selecting claim records from the NCH.5   This resulted 
in a file of 41,513,455 ultrasound claims representing $2,750,575,063 in 
 
3 Centers for Medicare & Medicaid Services (CMS), Medicare National Coverage 
Determinations Manual, Pub. No. 100-03, ch. 1,  220.5. 
4 PSCs are contractors tasked with detecting and deterring fraud and abuse in the  
Medicare program. 
5 Berenson-Eggers type of service groups organize Part B procedure codes into clinical 
categories that aid in analysis of Medicare services and expenditures. 
OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   2   
   
 I  N T R O D U C T I O N   
Medicare-allowed charges.  From this file, we used the procedure 
modifier codes on the claims to identify those for the technical  
component of ultrasound services.  This resulted in a file of 
18,836,768 claims representing $2,172,037,957 in allowed charges.  
From this file, we dropped 1,385,229 claims that had zero allowed 
charges and 423,675 claims with invalid county codes and invalid or 
missing billing provider identifiers.  Together these represented 
10 percent of ultrasound claims for the technical component  of services  
and $52,617,857, or 2 percent, of allowed charges.  Thus our final 
analysis included 17,027,864 ultrasound claims representing 
$2,119,420,100 of allowed charges. 
Next, we summarized the claims by county to generate totals of 
ultrasound services, allowed charges, and beneficiaries who received 
ultrasound in each of the 3,239 counties that had ultrasound claims.  
We used the 2007 Denominator File to obtain a count of 
fee-for-service beneficiaries in each county as of July 1, 2007.  We then 
merged these files to calculate utilization measures for each county.  
They included average allowed charges and services per beneficiary and 
percentage of beneficiaries receiving services.  
After analyzing this file, we defined  high-use counties as those that 
ranked in the top 1 percent for both of the following measures: 
 	  average allowed charges for ultrasound per fee-for-service 
beneficiary, and 
 	  the percentage of fee-for-service beneficiaries who received  
ultrasound services. 
Of the 3,239 counties in our analysis, 20 were in the top 1 percent for 
both of the measures above.   Nine of these counties were in  Florida; five  
in New York; three in New Jersey; and one each in Alabama, Michigan, 
and Texas. See Figure 1 for a map showing the locations of these 
counties.  
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   3   
   
I N T R O D U C T I O N
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Analysis of Billing Patterns 
We analyzed our county-level file and our national claims file to 
describe utilization in the high-use counties and to compare utilization 
in the high-use counties to that of all other counties.  In consultation 
with a certified fraud examiner and a registered sonographer at a PSC, 
we identified five characteristics that may indicate questionable 
ultrasound claims. These characteristics were: 
 	  The absence of a prior service claim from the doctor who ordered the  
ultrasound service.  We identified the ordering doctor reported on 
each ultrasound claim and determined whether the doctor had a 
service claim for treating the beneficiary any time from 2006 up to 
and including the date of the ultrasound service.  Such an absence 
raises questions as to whether the doctor who reportedly ordered the 
service ever  saw the beneficiary. 
 	  Questionable use of ultrasound billing codes, such as suspect 
combinations of ultrasound services billed for the same beneficiary 
on the same day by the same provider, or specific procedures that 
are not effective in adults. An example would be duplicative 
services, such as billing for both a complete abdominal scan and a 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   4   
   
I N T R O D U C T I O N   
scan of an individual organ within the abdominal cavity.  This raises 
concerns of unnecessary or inappropriate use of services. 
 	  Instances of more than five ultrasound services provided to the same  
beneficiary on the same day by the same provider.  This raises 
concerns of excessive utilization of services. 
 	  Beneficiaries who had ultrasound services billed for them by more 
than five providers in 2007. This raises concerns of misuse of 
beneficiaries Medicare numbers. 
 	  Missing or invalid data in the claim fields that identify the doctor 
who ordered the service.  This raises  questions about whether the 
service was ordered by a physician treating the beneficiary. 
We created variables to show the  presence  or absence of each of these 
characteristics on each claim.  We analyzed them to determine the  
extent to which ultrasound claims exhibited these characteristics and 
the extent to which high-use counties and all other counties varied in 
their prevalence. 
Limitations 
This study relies on claims and enrollment data from CMS.  We did not 
independently verify these data.  
The five characteristics we used to identify questionable claims for  
ultrasound  are not intended to be a comprehensive set of markers for  
identifying questionable claims.  Also, although the presence of such 
characteristics raises questions about the appropriateness of claims, it 
does not necessarily mean that such claims are inappropriate or 
fraudulent.  We did not assess compliance of ultrasound claims with 
Medicare billing requirements or the medical necessity of their 
underlying services. 
The Health Insurance Portability and Accountability Act of 1996 
required issuance of a unique national provider identifier (NPI) to each  
physician, supplier, and other health care providers.  CMS began 
issuing NPIs on May 23, 2005; however, it was not until May 23, 2008, 
that CMS required all claims to have an NPI.6  In the interim, CMS 
allowed submitted claims to have the NPI only, the Medicare legacy  
identifier only (i.e., Unique Physician Identification Number), or a 
combination of an NPI and a Medicare legacy identifier on the claims. 
 
6 45 CFR  162.404 and 162.410. 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   5   
   
I N T R O D U C T I O N   
For calculations in this report, we excluded claims that had only an NPI 
for the billing provider and relied on the legacy numbers to identify the 
billing provider and ordering doctor.  We did so to simplify counting and 
matching claims by provider identifier. In 2007, less than 2 percent of  
ultrasound claims had only an NPI for the billing provider and less than 
1 percent had only an NPI for the ordering doctor. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency (now 
Council of the Inspectors General on Integrity and Efficiency). 
 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   6   
   
B A N N E R   2 N D   P A G E  
  F I N D I N G S  
 
In 2007, 20 high-use counties accounted for   The 20 high-use counties accounted 
16 percent of Part B spending on ultrasound  for $336 million, or 16 percent, of 
the $2.1 billion of Part B spending 
despite having only 6 percent of Medicare 
on ultrasound services. Similarly, 
beneficiaries  
high-use counties accounted for  
2.3 million, or 13 percent, of the 17 million ultrasound services that 
Part B covered in 2007.  
Average per-beneficiary spending on ultrasound in high-use counties was 
over three times that for beneficiaries in the rest of the country  
Part B spent an average of $171 on ultrasound for every beneficiary in 
the high-use counties compared to $55 in the rest of the country.  The 
average expenditure per individual in high-use counties ranged from  
$123 in Walker County, Alabama, and Sarasota County, Florida, to 
$235 in Kings County, New York.  See Table A1 in Appendix A for 
details on usage of ultrasound in the high-use counties. 
Twice as many beneficiaries received ultrasound services in high-use 
counties as in the rest of the country  
In the high-use counties, 36 percent of beneficiaries received ultrasound 
services in 2007 compared to only 18  percent in the rest of the country.  
The percentage of beneficiaries who  received ultrasound services in 
high-use counties ranged from 31 percent in Union County, New Jersey,  
to 42 percent in Miami-Dade County and Charlotte County, Florida.  
Beneficiaries in high-use counties who received ultrasound services 
received more services than those in the rest of the country  
Beneficiaries who received ultrasound services in the high-use counties  
received an average of 3.2 services compared to 2.5 services for 
beneficiaries in the rest  of the country.  The average Part B charge per 
beneficiary receiving ultrasound services in high-use counties was 
$474 versus $302 in the rest of the country. 
The ratio of ultrasound providers to beneficiaries in high-use counties was 
over three times that for the rest of the country  
In the high-use counties, the ratio of ultrasound  providers to  
beneficiaries was 1 for every 90 beneficiaries.  In  the rest of  the country, 
this ratio was 1 provider for every 329 beneficiaries.  In both the 
high-use counties and the rest of the country, over 90 percent of services 
were billed by doctors and under 10 percent were billed by group 
providers, such as multispecialty groups or IDTFs. 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   7   
   
F I N D I N G S  

 
Nearly one in five ultrasound claims nationwide  In 2007, 3.2 million, or 19 percent, 
had characteristics that raise concern about  of Part B ultrasound claims had 
whether the claims were appropriate  one or more  of the five 
characteristics we reviewed.  
These claims accounted for $403 million, or 19 percent, of the $2.1 
billion that Part B spent on ultrasound services in 2007.  The overall 
rate of ultrasound claims exhibiting one or more  of these characteristics 
was the same in high-use counties as in all other counties.  See Tables 1 
and 2 for descriptions of the characteristics and the number of claims 
and allowed charges that each characteristic represents. 
Lack of a service claim by the ordering doctor was the most common of the 
questionable characteristics overall 
About 2.8 million, or nearly 17 percent, of Part B ultrasound claims 
billed in 2007 lacked prior service claims by the ordering doctor. These 
claims account for nearly 15 percent  of claims from high-use counties  
and 17 percent of claims from all other counties.  For these claims, the 
ordering doctor did not bill Part B for treating the beneficiary, such as 
for an office visit, any time in 2006 or 2007 up to and including the day 
of the ultrasound service.  These claims account for $356 million in 
Part B charges.  Ultrasound claims  without prior service claims raise 
questions because they suggest that the doctor who ordered the service 
may never have seen the beneficiary. When an ultrasound claim was 
accompanied by a service claim, the service claim fell on the same day 
or within 30 days prior to the ultrasound claim 72 percent of the time. 
Further, 4 percent of billing providers, or 4,525, lacked preceding or 
same-day service claims from the ordering doctors for all ultrasound  
claims they billed.  Although most of these providers billed fewer than 
10 ultrasound claims during the year, 92 providers billed more than 
100 claims each and 1 billed 5,066 claims. In 2007, these 92 providers 
collectively billed Part B for 34,673 ultrasound claims, accounting for 
$4.8 million of allowed charges. 
The other questionable characteristics were far less common but more 
prevalent in high-use counties than other counties 
About half a million, or 3 percent, of Part B ultrasound claims had at 
least one of the other four characteristics we reviewed, such as 
questionable use of procedure codes.  These claims account for 5 percent 
of claims from high-use counties compared to 2.7 percent of claims from 
all other counties.  They represent about $63 million in allowed charges. 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   8   
   
F I N D I N G S  
Tables 1 and 2 show the number of  Part B ultrasound claims and the 
allowed charges that each questionable characteristic represents.  
 
Table 1:  Part  B Ultrasound Claims With  Questionable  Characteristics,  2007 
 
High-Use Counties  All Other Counties 
 
Number of   Percentage of   Number of   Percentage of  
Questionable Characteristic    Claims*  Claims*  Claims*  Claims* 
Claim lacked a prior service claim  from the doctor who ordered the  331,993  14.5%  2,496,149  16.9% 
service 
 
Claim involved questionable use of ultrasound procedure  55,808  2.4%  231,928  1.6% 
codes** 
 
Claim was  for one of more than five services provided to the same   33,458  1.5%  101,777  0.7% 
beneficiary on the same day by t he same provider 
Claim was  for a beneficiary  who  had ultrasound  services  billed for   31,024  1.4%  12,966  0.1% 
him or her  by  more than five providers in  2007 
 
Claim had missing or  invalid data in the field that identifies  the  7,097  0.3%  66,287  0.5% 
doctor who ordered the service 
 
     Unduplicated total              423,862  18.5%           2,765,452  18.8% 
 
*Claims may  have had more than one questionable characteristic. 

**See Tables A2 and A3 in Appendix A  for  details  on questionable uses of procedure codes. 

Source:  OIG analysis of the Medic are National Claims History  File, 2007. 

 
Table 2:  Allowed  Charges for  Ultrasound  Part  B Claims  With Questionable Characteristics, 2007 
 
High-Use Counties  All Other Counties 
 
Percentage of   Percentage of  
Allowed   Allowed   Allowed   Allowed  
Questionable Characteristic    Charges*  Charges*  Charges*  Charges* 
 
Claim lacked a prior service claim from the doctor who ordered the  $49,124,035  14.6%  $306,924,252  17.2% 
service 
 
Claim involved questionable use of ultrasound procedure  $7,622,384  2.3%  $27,336,668  1.5% 
codes**   
Claim was  for one of more than five services provided to the same   $5,226,099  1.6%  $14,494,316  0.8% 
beneficiary on the same day by t he same provider 
Claim was  for a beneficiary  who  had ultrasound  services  billed for   $4,321,776  1.3%  $1,331,304  0.1% 
him or her  by  more than five providers in  2007 
 
Claim had missing or  invalid data in the field that identifies  the  $846,112  0.3%  $6,495,270  0.4% 
doctor who ordered the service 
 
$62,403,039  18.6%  $340,235,572  19.1% 
     Unduplicated total 
*Claims may  have had more than one questionable characteristic. 

**See Tables A2 and A3 in Appendix A  for  details  on questionable uses of procedure codes. 

Source:  OIG analysis of the Medicare National Claims History  File, 2007. 

  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   9   
   
F I N D I N G S  

 
Certain providers billed for a large number of  Although most of the 
ultrasound claims with questionable  104,598 providers who billed for 
ultrasound billed 20 or fewer 
characteristics 
claims with questionable 
characteristics, 672 each billed Part B for 500 or more such claims in 
2007. On average, about half of the ultrasound claims billed in 2007 by 
these providers had questionable characteristics associated with them.  
Collectively, these claims accounted for 588,534 of the 
1,412,459 ultrasound claims they billed to Part B, accounting for 
$81 million of their $192 million in allowed charges for ultrasound. 
 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   10   
   
  R E C O M M E N D A T I O N S  
 
This report found that Medicare beneficiaries in a small group of 
counties with the highest use of ultrasound received a disproportionate 
number of services compared to beneficiaries in other counties.  In these 
counties,  more beneficiaries received  ultrasound services, and  when 
they received them, they received  more services from more providers.   
These factors drive per-beneficiary Part B spending on ultrasound  
services that is three times that in other counties. 
In addition, nearly one in five claims billed for ultrasound services 
under Medicare Part B in 2007 had characteristics that raise concern 
about their appropriateness.  This rate is consistent when comparing 
high-use counties to all other counties.  Such claims account for 
3.2 million services and represent $403 million in Part B charges. 
Given our findings, we recommend that CMS: 
Monitor Ultrasound Claims Data To Detect Questionable Claims 
This would reduce Medicares vulnerability to questionable claims for 
ultrasound services by enabling CMS to develop claims-processing edits 
that flag them for review prior to payment.  As part of its analysis, CMS 
should examine claims for characteristics that are readily identifiable, 
such as suspect combinations of services for the same beneficiary on the 
same day, and those that become evident across beneficiaries and 
providers claims over time. 
Take Action When Providers Bill for High Numbers of Questionable Claims 
for Ultrasound Services 
When its monitoring identifies providers that bill for large numbers of 
questionable claims, CMS should review the claims to ensure that they  
are legitimate prior to payment.  If  CMS determines that such providers 
submit fraudulent claims, it should take steps to  revoke their Medicare 
billing numbers.  Toward that end, we will provide CMS with 
information on the providers that we identified as having submitted  
high numbers of questionable ultrasound claims. 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
In its written comments on this report, CMS concurred with both of our  
recommendations.  In response to our recommendations, CMS will 
share our findings with the Medicare Administrative Contractors for 
potential additional prepay edits and prepay medical review.  CMS also  
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   11    
   
R E C O M M E N D A T I O N S  
stated that it will forward questionable claims identified by this report 
to its Recovery Audit Contractors for them to consider in prioritizing 
areas for postpayment review. Finally, CMS stated that it will share 
with its program integrity contractors for appropriate followup 
information on providers that OIG provides. 
We did not make any changes to the report based on CMSs comments.  
For the full text of CMSs comments, see Appendix B.  We have provided  
CMS with information  on the providers that we identified as having 
submitted high numbers  of questionable claims.  
 
 
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  A P P E N D I X ~ A
Table A-1:  Ultrasound Covered Under Part B in High-Use Counties, 2007 
 
Percentage of  
 
Beneficiaries 
Beneficiary   Receiving  Allowed Charges  Average Charges 
 
County and State  Population  Ultrasound  for Ultrasound  per Beneficiary 
 
Kings, NY   213,049  35%  $50,067,967   $235 
 
Miami-Dade, FL   182,733  42%  $42,374,761   $232 
 
Nassau, NY   182,738  39%  $36,985,652   $202 
 
Willacy, TX   2,692  41%  $524,329   $195 
Suffolk, NY     189,873  35%  $34,399,935   $181 
Queens, NY     194,434  33%  $34,250,651   $176 
Richmond, NY     41,697  32%  $6,850,116   $164 
Palm Beach, FL     182,177  40%  $27,980,686   $154 
Charlotte, FL     34,351  42%  $4,961,687   $144 
Union, NJ   67,657  31%  $9,747,483   $144 
 
Middlesex, NJ   94,291  33%  $13,306,923   $141 
 
Saint Lucie, FL  40,111  37%  $5,519,626   $138 
 
Macomb, MI   113,766  33%  $15,543,312   $137 
 
Broward, FL   136,416  33%  $18,461,816   $135 
 
De Soto, FL   4,779  37%  $641,599   $134 
 
Ocean, NJ   114,346  35%  $15,338,042   $134 
Marion, FL     73,343  39%  $9,748,060   $133 
Indian River, FL     30,932  38%  $3,993,748   $129 
Sarasota, FL     97,804  36%  $12,066,955   $123 
Walker, AL     12,636  35%  $1,558,896   $123 
Source:  Office of  Inspector Gen eral (OIG) analysis of  the Medicare National Claims History File, 2007. 
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A P P E N D I X - A  
Table A-2:  Part B Claims Involving Questionable Use of Ultrasound Procedure 
Codes, 2007  
 
High-Use Counties   All Other  Counties 
 
Questionable Use   Number of   Percentage  Number of   Percentage 
Claims*  of Claims*   Claims*  of Claims* 
 
Claim involved  a combination of procedures billed for the same  
beneficiary,  on the same  day, by  the same provider: 
76700   Ultrasound, abdominal, real time with image 
 
documentation, complete 
76705   Ultrasound,  abdominal, limited (e.g., single organ, 
quadrant, followup)   911  0.04%   4,554  0.03% 
 
76830   Ultrasound, transvaginal documentation, complete 
76856   Ultrasound,  pelvic (nonobstetric), real time with image 
documentation, complete  29,242  1.27%   152,688  1.04% 
 
93925   Duplex scan of lower extremity arteries or arterial 
bypass graf ts; complete bilateral study 
93978   Duplex scan of aorta, inferior vena cava, iliac 
vasculature , or bypass grafts; complete study  18,826  0.82%   71,926  0.49% 
 
Claim involved  a procedure that is not indicated for use in  
adults:    
76800   Ultrasound, spinal canal and contents  6,861  0.30%   2,848  0.02%
 
     Unduplicated total  55,808  2.43%   231,928  1.57% 
*Claims may have involved multiple questionable uses of  ultrasound procedure codes. 
Source:  OIG analysis of  the Medicare National Claims History File, 2007. 
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A P P E N D I X ~ A  
Table A-3:  Allowed Charges for Part B Claims Involving Questionable Use of 
Ultrasound Procedure Codes, 2007  
 
High-Use Counties   A ll Other Counties 
  Percentage of   Percentage of  
Questionable Use  Allowed  Allowed  Allowed  Allowed 
  Charges  Charges   Charges  Charges 
Claim involved  a combination of procedures billed for the same  
beneficiary,  on the same  day, by  the same provider: 
 
76700  Ultrasound, ab dominal, real time with image 
 
documentation, complete 
 
76705  Ultrasound, ab dominal, limited (e.g., single organ, 
   
quadrant, followup)  $107,139  0.03%  $616,248  0.03% 
   
76830  Ultrasound, transvaginal documentation, complete 
 
76856  Ultrasound, pelvic (nonobstetric), real time with image 
     
documentation, complete  $3,554,520  1.06%  $15,638,645  0.88% 
   
93925  Duplex scan of lower extremity arteries or arterial 
bypass grafts; complete bilateral study 
  93978   Duplex scan of aorta, inferior vena cava, iliac 
 
vasculature, or bypass grafts; complete study  $3,190,638  0.95%  $10,745,783  0.60% 
 
Claim involved  a procedure that is not indicated for use 
 
  in adults: 
   
76800  Ultrasound, spinal canal and contents  $774,107  0.23%  $347,109  0.02%
 
     Unduplicated total   $7,622,384  2.27%   $27,336,668  1.53% 
 
*Claims may have involved multiple questionable uses of  ultrasound procedure codes. 
Source:  OIG analysis of  the Medicare National Claims History File, 2007. 
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   15   
   
  A P P E N D I X ~ B
Agency Comments 
 
 
SE~ICF.S
DEPARTMEf\.lTOFHEALTH& HUMAN
 
200tncMopIo_......_ sw
W8sh1ngtQn.OC 20201
 
 
DATE: MAY 1 12009
 
TO: Daniel R.Levinson
InspectorGcncral
  C' ..
1.-<-3-<'J}"'~
FROM: ~nc Fn7.7.cTa
  AClingAdministrator
  SUBJECf: OfficeofInspcctorGencral(DIG)DraftReport:"MedicareI)artBBillingfor
Ultrasound"OEI-OI-Og-ooloo
 
Thankyou fortheopportunitytoreviewandcommentontheabove-referencedDIGdraftreport.
 
Medicare Part Bcoversultrasoundservicesprovidedinambulatorysettings.suchasdoctors'
  officesandtcstingcenters. In2007.Medicarespentover$2billion forabout 17million
ultrasoundservices. TheDIG found,amongotherthings.ahighconcentr.ltionofultrasound
providersand/orservicesincertaincounties, whichmayindicateareaswhereMedicare's
 
programSllfegul,rdeITonsshouldbeenhanced.
 
TheOlG reportedlhal in2007.20high-usecountiesaccountedfor 16percentofPartBspending
onultrawundservicesdespitehavingonly6percentofMedicarebeneficiaries. TheDIGalso
  found 3.2millionclaimswithquestionablechnracteristicsthaIraiseconecrnsaboullhc
appropriatcnessofthcseclaims. Theseclaimsrepresent$403 million in Part Bcharges.
  Furthermore,thc010 found thaIth~avcrageper-beneficiaryspendingon ultrasoundserviccsin
the20high-usccountieswasmorethanthrectimesthatforbeneficiaricsintherest ofthe
country.
 
TheDIG found thatlackofa priorserviceelaim bythcorderingdoctorwasthemostcommon
  questionablecharactcristic. Othercharacteristics.suchasquestionableuscofprocedurecodes.
wcrelesscommonbulmoreprevalentinhigh-usccountiesthanothercounties. Inaddition,
  certainprovidersbilledfor alargenumberofultrasoundclaimswithquestionablecharacteristics.
suchassuspectcombinationsofultrasotmdservicesforthesamebeneficiary.
 
TheDIGmadethefollowing re<:ommendalions:
  DIG RttGmmt-ndation
  Monitorultrasoundclaimsdatatodetectqucstionableclaims.ThiswouldreduceMedicare's
vulnerabilitytoquestionableclaimsforullrasoundservicesbyenablingeMStodevclopclaims
processingeditsthat nagthesequcstionableclaimsforreviewprior10payment.
 
 
 
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A P P E N D I X ~ B  

 
 
Page2- Danicl R. Levinson
 
 
eMS Rcs(lllllse
 
TheCMSconcurs. CMSwillsharetheOIG findingsonquestionableultrasoundclaimswiththe
MedicareAdministrativeContraetors(MACs)forpotentialadditional prepayeditsandprepay
 
medicalreview. CMSwill informMACsofthisissuesothattheymayconsideritwhen
prioritizingtheirmedicalreviewstrntcgiesaspartoftheCMSefforttoprotecttheMedicareI'art
I
  DTrustFund.
DIG Recommendation
 
Takeaction whenprovidersbill for highnumbersofquestionableclaimsforuhrdSOundservices.
 
Whenitsmonitoringidentifiesprovidersthatbill forlargenumbersofquestionableclaims,CMS
shouldrevicwthcirclaimstoensurethattheyarelegitimatepriortopayment. IfCMS
  determinesthatsuchproviderssubmitfraudulcntclaims,itshouldtakestepstorevokelheir
Medicarebillingnumbers.
 
 
ThcCMSconcurs. eMSwill takeappropriateactiontoforwardthelistingofqucstionable
claimstothe RecoveryAuditContractors(RACs)andMACs. The RACsrevicwMedicare
  claimsonapostpaymentbasisandaretaskedwith identifyinginappropriatepayments. While
CMSdocsnotmandatcareasforRACreview,wewill sharelhisinfonnationwiththem. We
willinstructtheMACstoconsiderlhisultrasoundissuewhenprioritizingtheirmedicalreview
strntcgies.
lbeDIGhasrecommendedthateMStakeactionifitdeterminesthatultrasoundproviders
submitfraudulentclaims. WerequesttheDIGsharewithCMStheinformationonthose
providerstheybelievemay havebeeninappropriatelypaid. WhenCMSreceiveslhis
information,wewillsharcil withourintegritycontractorsforappropriateaction. Insomecases,
thecontractorsmaytakeadministrativcaction(s)includingplacingtheprovideronprepayment
review,collcctingoverpayments,and/orinitiatingpaymentsuspensions. Additionally,for
reviewsthatresultinfindingsofpotential fraud, thecontractormaydevelopacase forreferralto
theDIG foradditionalaction.
TheCMSthankstheDIGfor itseffortsonthisrcponand forhighlightinglhispotential
vulnerabilityintheMedicareprogram. eMS iscommittedtocontinuallyreviewingandrefining
ourprocessestoimprovetheMedicareprogram,andwewill takethefindingsofthisreport
underconsiderationaswecontinuetostrengthenouroversighteffortstofurtherreduceimproper
paymentsintheMedicareprogram. Wclook forward tocontinuingtoworkwiththeDIGtp
identifyandpreventfraud, waste,and abuseintheMedicareprogram.
  OEI-01-08-00100   PART  B  BILLING FOR  ULTRASOUND   17   
   
  A C K N O W L E D G M E N T S
 
This report was prepared under the  direction of Joyce M. Greenleaf, 
Regional Inspector General for Evaluation and Inspections in the 
Boston regional office, and Russell W. Hereford, Deputy Regional 
Inspector General.    
Kenneth Price served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Boston regional 
office who contributed to the report include Rosemary Borck and 
Carolyn Kenline; other regional and central office staff who contributed 
include Kevin Farber, Scott Horning, Scott Hutchison, and Kevin 
Manley. 
 
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