Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
Q B
UE  STIONABLE  ILLING FOR 
 
M
  EDICARE 
 
E T
LECTRODIAGNOSTIC  ESTS 
 
Daniel R. Levinson   
Inspector General  
 
April 2014 
OEI-04-12-00420   
   
EXECUTIVE SUMMARY:  Questionable Billing for Medicare 
Electrodiagnostic Tests 
OEI-04-12-00420 
 
WHY WE DID THIS STUDY 
 
In 2011, Medicare paid approximately $486 million to 21,700 physicians who billed for 
electrodiagnostic tests for 877,000 beneficiaries. Electrodiagnostic tests are used to 
evaluate patients who may have nerve damage.  Recent investigations have found that 
electrodiagnostic testing is an area vulnerable to fraud, waste, and abuse.  For example, in 
2011, following work by the Medicare Fraud Strike Force, a group of physicians was 
charged with fraudulently billing Medicare $113 million for false claims, including 
claims for electrodiagnostic tests.  The Centers for Medicare & Medicaid Services (CMS) 
issues comparative billing reports to providers for a variety of services, including 
electrodiagnostic testing.  Such reports are intended to proactively educate providers and 
to help them identify and correct errors in their billing.  
 
HOW WE DID THIS STUDY  
 
We developed seven measures of questionable billing on the basis of past Office of 
Inspector General work and input from CMS staff.  We analyzed Medicare 2011 
electrodiagnostic test claims to identify physicians who had unusually high billing for at 
least one of these measures.  We also determined whether physicians with questionable 
billing for electrodiagnostic tests received comparative billing reports in 2011 for such 
tests. Finally, we identified the geographical areas with the highest amounts of 
questionable billing. 
 
WHAT WE FOUND 
 
In 2011, 4,901 physicians had questionable billing for Medicare electrodiagnostic tests 
totaling $139 million.  Additionally, we found that approximately 20 percent of these 
physicians received comparative billing reports in 2011 on the basis of their 2010 billing 
for electrodiagnostic tests. Finally, physicians in the New York, Los Angeles, and 
Houston areas had the highest total questionable billing for Medicare electrodiagnostic 
tests in 2011. 
 
WHAT WE RECOMMEND   
 
We recommend that CMS (1) increase its monitoring of billing for electrodiagnostic 
tests, (2) provide additional guidance and education to physicians regarding 
electrodiagnostic tests, and (3) take appropriate action regarding physicians whom we 
identified as having inappropriate or questionable billing.  CMS partially concurred with 
our first two recommendations and concurred with the third one. 
   
 
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................6 

Findings......................................................................................................11 
 
In 2011, 4,901 physicians had questionable billing for Medicare 
electrodiagnostic tests totaling $139 million .................................11 
 
Thirty-eight percent of physicians with questionable billing for 

electrodiagnostic tests were in 10 metropolitan areas ....................17 

Conclusion and Recommendations ............................................................19 

Agency Comments and Office of Inspector General Response .....21 

Appendixes ................................................................................................22 

A: Number and Percentage of Medicare Physicians With 

Questionable Billing for Electrodiagnostic Tests in Each  

Specialty, 2011  ...............................................................................22 

B: Number and Percentage of Medicare Physicians Who  

Exceeded Thresholds of Questionable Billing for  

Electrodiagnostic Tests by Specialty Group, 2011 ........................24 

C: Physicians With Unusually High Billing by Each Measure of 
 
Questionable Billing, 2011  ............................................................25 

D: Metropolitan Areas With the Highest Number of Physicians 

With Questionable Billing by Specialty Group, 2011 ...................27 

E: Geographical Areas of Physicians With Three Measures of 

Questionable Billing, 2011  ............................................................28 

F: Geographical Areas of Top 10 Physicians With Questionable 

Billing, 2011 ...................................................................................30 

G: Agency Comments  ...................................................................31 

                       Acknowledgments.......................................................................................35 
 
 
 
   
   
OBJECTIVES 
To determine the extent to which: 
1. 	  physicians exhibited questionable billing for electrodiagnostic tests in 
2011, and 
2. 	  questionable billing by physicians varied by geographical location. 
BACKGROUND 
Recent investigations have found that electrodiagnostic testing is an area 
vulnerable to fraud, waste, and abuse.  For example, in 2011, the Medicare 
Fraud Strike Force charged a group of physicians in two cities with 
fraudulently billing Medicare $113 million for false claims, including 
claims for electrodiagnostic tests.1  Further, the growth of Medicare 
spending on electrodiagnostic testing has outpaced the growth in overall 
Medicare spending in recent years.  From 2002 to 2011, spending for 
electrodiagnostic testing under Medicare Part B increased 74 percent, from 
$279 million to $486 million.2  In comparison, during the same timeframe, 
overall Medicare spending for Part B items and services increased 
50 percent.3    
Overview of Electrodiagnostic Tests 
Electrodiagnostic tests are used to evaluate patients who may have nerve 
damage.  These specialized tests measure the electrical activity of the 
muscles and nerves and detect abnormalities of the peripheral nervous 
system (i.e., nerves outside the brain and spinal cord).   
Several conditions, including diabetes and carpal tunnel syndrome, can 
cause peripheral nerve damage.  Two common electrodiagnostic tests to 
 
1 The Detroit, MI, cases involve  $23 million in false Medicare claims for home health  
care, nerve conduction tests, psychotherapy, physical therapy and podiatry.  The 
Brooklyn, NY, cases involve $90 million in  false Medicare billings for physical therapy, 
proctology services and nerve conduction tests.  Department of Justice, Medicare Fraud 
Strike Force Charges 111 Individuals for More  Than $225 Million in False Billing and 
Expands Operations to Two Additional Cities. Accessed at  
http://www.justice.gov/opa/pr/2011/February/11-ag-202.html on June 8, 2012.  
2 In 2011, Medicare spending on electrodiagnostic tests represented approximately 
0.4 percent ($486 million  of $126 billion) of  all Medicare Part B spending.  Health and  
Human Services (HHS)  Office of Inspector  General (OIG)  analysis of  2002 and 2011 
Part B Analytics Reports (PBAR) National Procedure Summary File.   
3 Ibid. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              1  
   
   
assess nerve damage are nerve conduction tests (NCT) and needle 
electromyography tests (EMG).4     
NCTs. NCTs are noninvasive procedures used to evaluate muscle or nerve 
damage.  Standard NCTs include a stimulus that delivers a small electrical 
current to the patients skin near the nerves being tested, causing the 
nerves to respond. The electrical signals produced by nerves and muscles 
are typically recorded and interpreted by a physician specifically trained in 
electrodiagnostic medicine.  Results from NCTs provide information about 
the speed, size, and shape of the nerve in response to an electrical 
stimulus.  Physicians typically test many different motor and sensory 
nerves to determine the presence of nerve damage.  
Needle EMGs. Needle EMGs are invasive procedures that provide 
information about the function of the muscles and nerves in the body.  
Depending on the patients symptoms, a needle is inserted into muscles in 
the arm, leg, neck, or back.   For example, patients with lower back pain 
may experience nerve pain from herniated discs.  In this case, a needle 
EMG can evaluate the severity of the nerve damage caused by disc 
herniations. Results from needle EMGs provide information about the 
integrity of the connection between a nerve and its muscle as well as the 
integrity of the muscle itself.  Typically, physicians trained specifically in 
electrodiagnostic medicine perform  and interpret the results from the 
needle EMG.  
Typically, physicians perform NCTs along with needle EMGs to detect, 
measure and confirm the extent of nerve damage.5,6   When performed 
together, these tests can determine the source of nerve pain and damage 
and whether such pain is related to peripheral nerve disease.  However,  
when physicians use NCTs without integrating needle EMG findings, the 
results may be misleading, potentially causing important diagnoses to be 
missed.7    
 
4 American Association  of  Neuromuscular  & Electrodiagnostic Medicine (AANEM), 
Model Policy for Needle Electromyography and Nerve Conduction Studies,  
December 2011. Accessed at http://www.aanem.org/getmedia/4258c924-358e-42ce-
a64e-1c6a935f2e2e/Model_Policy_NCS_EMG_12312011.pdf.aspx on  June 7, 2012. 
5 AANEM,  Proper Performance and Interpretation of Electrodiagnostic Studies, 
January 2006.  Accessed  at http://www.aanem.org/getmedia/9b4fa3d5-c127-4c3d-9296-
b650e443b2cc/ProperPerformance.pdf.aspx on  July 2,  2012. 
6 Needle EMGs are optional  when diagnosing carpal tunnel  syndrome.  American 
Association of  Electrodiagnostic Medicine (now AANEM),  Practice Parameter for 
Electrodiagnostic Studies in Carpal Tunnel Syndrome:  Summary Statement, June  2002.  
Accessed at http://www.aanem.org/getmedia/7ddc9ef9-ee91-4b48-9c1a-53454313001e/ 
CTS.pdf.aspx on December 23, 2013. 
7 Ibid.    
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              2  
   
   
Medicare Payment for Electrodiagnostic Tests    
Medicare Part B pays for electrodiagnostic tests that are medically 
reasonable and necessary, and performed by physicians or by licensed, 
certified nonphysician personnel under appropriate physician 
supervision.8,  9  Further, Medicare requires that diagnostic tests, including 
electrodiagnostic tests, be ordered by a physician or other qualified 
nonphysician practitioner who treats a Medicare patient for a specific 
medical problem and who uses the results of those tests to manage the 
patients medical condition.10    
The Medicare fee schedule for physicians sets payment rates for 
electrodiagnostic tests on the basis of the location where the physician 
performed the service.11  In 2011, Medicares payment amounts for NCTs  
ranged from $46 to $84 and its payment amounts for needle EMGs ranged 
from $57 to $174.   
Medicare Claims Processing and Program Safeguards 
The Centers for Medicare & Medicaid Services (CMS) uses local 
contractors, known as Medicare Administrative Contractors (MAC) to 
manage payments for Part B services.  CMS and its contractors develop 
guidance and implement program safeguards to ensure the integrity of 
these services. For example, MACs can develop local coverage 
determinations (LCDs) that establish  billing and coding guidelines in their 
coverage areas when there is no National Coverage Determination (NCD) 
or when there is a need to further define an NCD.  To illustrate, MACs can 
establish LCDs that set utilization limits or clinical requirements for 
specific types of electrodiagnostic test claims in their coverage areas.  
These coverage rules can vary across MAC jurisdictions.12    
Additionally, LCDs inform physicians as to the correct use of modifiers 
and diagnoses on a claim. For example, some LCDs state that modifier 59 
should be added to a claim if the physician is conducting needle EMG 
 
8  Social Security Act  1862(a)(1)(A), 42 U.S.C.  1395y(a)(1)(A).   

9 Medicare does not pay  for electrodiagnostic  services performed by chiropractors. 
        
42  CFR  410.21(b)(2);  CMS,  Medicare Benefits Policy Manual, Pub.  No. 100-02, 

ch. 15,  30.5. 
 
10 42 CFR   410.32. 

11 Social Security Act  1848, 42 U.S.C. 1395w-4.  The Medicare physician  fee schedule 

is derived using a resource-based relative value scale, which includes three  resource 

components:  (1) total physician work, (2) practice expenses, and (3) malpractice 

expenses.  These payment rates are based on relative value units, adjusted for geography, 

and multiplied by a national conversion factor to derive dollar amounts.   

12 CMS, A/B MAC Jurisdictions. Accessed at http://www.cms.gov/Medicare/Medicare-
Contracting/MedicareContractingReform/PartAandPartBMACJurisdictions.html on 

June 22, 2012.  All  12 A/B  MAC jurisdictions were  operational  as of September 2013.   

Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              3  
   
   
testing on more than one limb during the same day.13  Further, since 
physician exams are typically performed with electrodiagnostic tests, 
some LCDs state that modifier 25 should be added to a claim if a separate, 
identifiable physician visit is billed by the same physician on the same  
day.  
CMS also uses what it calls medically unlikely edits (MUEs) to reduce 
the paid-claims error rate for Part B claims.  For example, an MUE may 
establish the maximum units of service for which a physician can bill 
under most circumstances for a single patient on the same day.14  In 2011, 
CMS had an MUE stating that the maximum units of service (in this 
case, the maximum number of tests) for a single NCT (procedure code 
95905) were two tests for a patient on the same day.15, 16   
Further, MACs may adopt practice guidelines developed by medical 
organizations to determine whether Medicare will cover an 
electrodiagnostic service. For example, several MACs have adopted 
AANEM guidelines stating that a needle EMG should be performed by a 
physician with special training in electrodiagnostic medicine, usually a 
physiatrist or neurologist.17  Physiatrists and neurologists receive formal 
 
13 Modifiers  25 and 59 are  used  to identify procedures that are typically not separately 
payable to make them eligible for separate payment.  Under certain circumstances, it may 
be appropriate for these procedures to be paid for separately.  For example, modifier 25 is  
used to indicate that a distinct evaluation and management (E/M) service was performed 
by the same physician on the  same day as an NCT or  needle EMG. Modifier 59 is  used to  
indicate that a  distinct, non-E/M service was performed by  the same physician on the 
same day as an NCT or needle EMG at a different session, at a different anatomical site, 
or on a different organ system. 
14 An edit is an automated system process to  ensure proper payment of claims.  An MUE 
flags claims for services or combinations of  services that are unlikely to be medically 
appropriate. CMS, Medically Unlikely Edits. Accessed at http://www.cms.gov/  
Medicare/Coding/NationalCorrectCodInitEd/MUE.html  on June 20, 2012.    
15 Not all procedure codes have an MUE.   Units of service for procedure code 95905 are  
based on each extremity (i.e., limb) tested, whereas  units of service for other NCT codes  
(e.g., 95900) are based on each nerve tested.  AANEM has recommendations for the 
maximum number of electrodiagnostic tests considered  reasonable to diagnose a patients  
condition.  In  2012, CMS worked with professional associations, including  AANEM, to  
allow physicians to use revised CPT  codes  on claims that indicate the number of 
electrodiagnostic tests that were performed.  However, CMS did not implement any edits  
to enforce AANEM recommendations about the number  of tests. 
16 The five character codes and descriptions included in this report are obtained 
from Current Procedural Terminology (CPT), copyright 2012 by the American 
Medical Association (AMA).  CPT is developed by the AMA as a listing  of  
descriptive terms and five character identifying codes and modifiers for reporting 
medical services and procedures.  Any use of CPT outside of this design should refer 
to the most current version of the Current Procedural Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
17 AANEM,  Who is Qualified to Practice Electrodiagnostic Medicine?  May 1999.  
Accessed at http://www.aanem.org/getmedia/f96400ac-6534-4f9f-bddc-21231e241e0c/  
who_is_qualified.PDF.aspx on  June 6, 2012.    
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              4  
   
   
training in the diagnosis and treatment of neuromuscular diseases, and 
they are trained in the administration and interpretation of 
electrodiagnostic tests. Providers who are generally not considered to 
have special training in nerve disorders include primary care physicians, 
internists, chiropractors, orthopedists, podiatrists, and dermatologists.18,  19    
Additionally, CMS produces comparative billing reports (CBRs) for 
Part B items and services to help physicians prevent future improper 
billings and payments.20  These reports compare physicians billing and 
payment patterns to those of their peers in their respective States and 
across the Nation.21  As of November 2013, CMSs contractor had issued 
initial CBRs on eight topics, including electrodiagnostic testing.  The 
contractor had also issued followup CBRs on four of those eight topics, 
but it had not issued one on electrodiagnostic testing.  The purpose of a 
followup CBR is to present comparisons to the providers who received the 
initial CBR; the followup CBR uses more recent data.  In the CBR for 
electrodiagnostic testing, the measures of analysis were (1) the average 
number of services paid per beneficiary for NCTs and needle EMGs, 
(2) the amount paid to the provider for NCTs and needle EMGs, and 
(3) the percentage of NCTs paid for without a needle EMG on the same  
claim.    
Related Office of Inspector General Work 
This is OIGs first evaluation on electrodiagnostic tests.  However,  
previous OIG work has documented growth in other types of diagnostic 
imaging tests covered under Medicare Part B and has raised concerns 
about the appropriateness of those services.22,  23  For example,  OIG 
 
18 AANEM,  Model Policy for Needle Electromyography and Nerve Conduction  Studies, 
December 2011.  AANEM policy states that nonphysicians, such as physical therapists, 
chiropractors, and physician  assistants, do not have appropriate training and knowledge  
to perform and interpret NCTs and  needle EMGs, although they may perform NCTs 
under  direct physician supervision.  
19 The American Board of Electrodiagnostic Medicine (ABEM), an independent  
credentialing body established by AANEM, administers an annual examination to  
evaluate the specialized knowledge and abilities of technologists trained in  NCTs. 
AANEM,  AANEM News.  Accessed at http://www.aanem.org/getmedia/9970eb4f-fd3b-
4fff-961f-963b238390be/16.pdf.aspx  on July 3, 2012.  
20 Safeguard Services, LLC, CBR011020 Frequently Asked Questions. Accessed at  
http://www.safeguard-servicesllc.com/cbr/faqs2.asp#cbr011  on June 5,  2012.  CMS,  
through Safeguard Services, issued a comparative billing report for electrodiagnostic tests 
in December 2011 to a sample of 4,241 physicians.  The sample typically excludes 
neurologists, physiatrists, and independent  diagnostic testing  facilities. The results of 
physicians CBRs are not publicly available.  
21 Safeguard Services, LLC, Comparative Billing Report Services Overview. Accessed at 
http://www.safeguard-servicesllc.com/cbr/default.asp  on  June 5, 2012. 
 
22 OIG,  Growth in Advanced  Imaging Paid  Under the Medicare Physician Fee Schedule, 
 
OEI-01-06-00260.  October 2007. 

23 OIG,  Medicare Part B Billing for Ultrasound, OEI-01-08-00100.  July 2009. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              5  
   
   
identified 20 counties that accounted for $336 million in questionable 
billing on ultrasound services in 2007.  CMS concurred with OIGs 
recommendation for it to monitor ultrasound claims data to detect 
questionable billing and take action when physicians bill for high numbers 
of questionable claims for ultrasound services.   
Additionally, OIG determined the extent to which use of modifier 25 (i.e., 
billing for a significant, separately identifiable evaluation and  
management (E/M) service by the same physician on the same day as 
another procedure) met Medicare program requirements in 2002.24 Of the 
450 claims with modifier 25 selected for medical review, 35 percent did 
not meet program requirements.   
Further, OIG determined whether providers used modifier 59 (i.e., billing 
for a significant, separately identifiable non-E/M service by the same  
physician on the same day as another procedure) inappropriately during 
fiscal year 2003.25  Of the 350 claims with modifier 59 selected for 
medical review, 40 percent did not meet program requirements.  CMS 
concurred with OIGs recommendations for it to work with its contractors  
to reduce the number of claims submitted using modifiers 25 and 59 that 
do not meet program requirements.     
METHODOLOGY 
Data Collection and Analysis 
We analyzed 2011 electrodiagnostic claims from 100-percent paid claims  
from CMSs National Claims History (NCH) Carrier File.  We analyzed  
approximately 3 million claims for NCTs and needle EMGs billed by 
21,663 physicians in 2011.  We also analyzed all of these physicians 
2011 Part B claims from  CMSs NCH Carrier File. 
Identification of Physicians With Questionable Billing 
We developed seven measures of questionable billing on the basis of past 
OIG work and fraud investigations related to electrodiagnostic tests, as 
well as input from CMS staff and AANEM.26   We considered a physicians 
billing to be unusually high, or questionable, on each of the seven 
measures if it was greater than the 75th percentile plus 1.5 times the 
 
24 For example, see OIG, Use of Modifier 25, OEI-07-03-00470.  November 2005. 
25 For example, see OIG, Use of Modifier 59 to Bypass National Correct Coding  
Initiative Edits, OEI-03-02-00771.  November 2005. 
26  We also analyzed electrodiagnostic test payments that were made inappropriately to 
211  physicians because on the corresponding claims, the physicians did not list diagnosis 
codes that covered electrodiagnostic services.  These claims totaled  $92,464 (or 
0.02 percent)  of the total Medicare-allowed amounts for electrodiagnostic  tests in 2011.   
We will refer these physicians to CMS for appropriate action. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              6  
   
   
interquartile range.27  Although some of this billing may be legitimate, 
physicians who have an unusually high amount of questionable billing 
warrant further scrutiny.  
We classified physicians into two groups on the basis of their specialty to 
ensure that physicians billing was compared to that of their peers.  That is 
to say, we accounted for individuals who have special training in 
electrodiagnostic medicine, and therefore may see more patients who 
require electrodiagnostic testing, and may bill for more of these tests.  One 
group consisted of neurologists and physiatrists, and the second group 
consisted of the remaining physicians in other specialties.28  In 2011, 
Medicare paid $373 million to 11,292 neurologists and physiatrists for 
electrodiagnostic tests.  Additionally, in 2011, Medicare paid 
approximately $113 million to 10,371 physicians in other specialties for 
electrodiagnostic tests.   
For each measure of questionable billing, we included physicians whom  
Medicare paid for five or more electrodiagnostic tests.29   We also 
calculated the Medicare payment for each physicians claim that was 
associated with questionable billing.  The seven measures of questionable 
billing we developed were: 
Physicians with an unusually high percentage of electrodiagnostic test 
claims using modifier 59. For each physician, we determined the 
percentage of electrodiagnostic test claims that had modifier 59.  This 
modifier is used to bill for a significant, separately identifiable non-E/M 
service by the same physician on the same day as another procedure. 
However, payments for both services are appropriate only under certain 
circumstances.  Past OIG studies have found that some physicians and 
providers used this modifier to increase payments inappropriately.30    
Physicians with an unusually high percentage of electrodiagnostic test 
claims using modifier 25. For each physician, we determined the 
percentage of electrodiagnostic test claims that had modifier 25.  This 
 
27 This is a standard exploratory method for identifying members of a population  with  
unusually high values  on a given statistic compared to the rest of the population when  no  
established benchmarks exist.  For each measure of questionable billing, this method was 
used to establish separate thresholds for the two groups of physicians.  See J. W. Tukey,  
Exploratory Data Analysis, Addison-Wesley, 1977.  
28 Chiropractors were analyzed separately to determine inappropriate billing, and  we 
found that none received payment for electrodiagnostic tests in 2011.   
29A total of 280  physicians with  questionable billing  billed for fewer than  
5 electrodiagnostic tests in  2011.  These physicians represented  5.35  percent of  
physicians with  questionable billing and approximately $39,590 (or .008  percent) of the 
total Medicare-allowed amounts for electrodiagnostic tests in  2011. 
30 For example, see OIG, Use of Modifier 59 to Bypass National Correct Coding  
Initiative Edits, OEI-03-02-00771.  November 2005. 
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modifier is used to bill for a significant, separately identifiable E/M 
service by the same physician on the same day as another procedure. 
However, payments for both services are appropriate only under certain 
circumstances.  Past OIG studies have found that some physicians and 
providers used this modifier to increase payments inappropriately.31    
Physicians with an unusually high percentage of electrodiagnostic test 
claims. For each physician who was not a neurologist or physiatrist, we 
determined the percentage of electrodiagnostic test claims compared to all 
of their other Part B items and service claims.  High billing of 
electrodiagnostic tests by physicians in specialties other than neurology 
and physiatry is questionable because they may be overutilizing these tests 
to evaluate beneficiaries or billing for services that were never performed.  
Physicians with an unusually high percentage of electrodiagnostic test 
claims that did not include both an NCT and a needle EMG test.   For each 
physician, we determined the percentage of electrodiagnostic test claims  
that did not have both an NCT and a needle EMG on the same claim (i.e., 
claims that included one but not the other).  High billing of 
electrodiagnostic tests with such claims is questionable because these two 
tests are typically performed together.32  However, according to AANEM, 
needle EMGs are optional when diagnosing carpal tunnel syndrome.33   
Therefore, we did not count a physicians claims for an NCT performed 
without a needle EMG as questionable when the diagnosis code on the 
claim was carpal tunnel syndrome (i.e., International Classification of 
Disease Coding (ICD) 354.0).  
Physicians with an unusually high average number of miles between the 
physicians and beneficiaries locations. For each physician, we 
determined the average number of miles between the physicians practice 
location and beneficiaries mailing addresses.  Physicians with an 
unusually high average number of miles between the two are questionable 
because they may be billing for services that were not medically necessary 
or were never performed.   
Physicians with an unusually high percentage of beneficiaries for whom at 
least three physicians billed Medicare for electrodiagnostic tests. For 
each physician, we determined the percentage of beneficiaries for whom at 
 
31 For example, see OIG, Use of Modifier 25, OEI-07-03-00470.  November 2005. 
32 AANEM,  Proper Performance and Interpretation of Electrodiagnostic Studies, 
January 2006.  Accessed  at http://www.aanem.org/getmedia/9b4fa3d5-c127-4c3d-9296-
b650e443b2cc/ProperPerformance.pdf.aspx on  July 2,  2012.  
33 AANEM,  Practice Parameter for Electrodiagnostic Studies in Carpal  Tunnel  
Syndrome: Summary Statement, June  2002.  Accessed at 
http://www.aanem.org/getmedia/7ddc9ef9-ee91-4b48-9c1a-53454313001e/CTS.pdf.aspx  
on December 23, 2013. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              8  
   
   
least three physicians billed Medicare for electrodiagnostic tests in 2011.34   
When multiple physicians bill for services provided to the same  
beneficiary in a given period, there is potential for fraud (i.e., 
beneficiary-sharing). 
Physicians with an unusually high average number of electrodiagnostic 
test claims for the same beneficiary on the same day. For each physician, 
we determined the average number of electrodiagnostic test claims  
submitted for the same beneficiary on the same day in 2011.35  A high 
number of electrodiagnostic claims for the same beneficiary on the same  
day by the same physician is questionable because the physician may be 
overutilizing electrodiagnostic tests to evaluate the beneficiary on the 
same day, or billing for services that were never performed. 
We also determined whether physicians with questionable billing received 
CBRs on electrodiagnostic testing in 2011.  To do this, we matched the 
National Provider Identifiers of physicians with questionable billing to 
those of physicians who received CBRs in 2011.  These CBRs were sent to 
physicians who billed for electrodiagnostic tests in 2010 to help them  
prevent future improper billing and payments.  We calculated the total 
number of physicians with questionable billing who received CBRs and 
determined the payments for questionable billing for these physicians. 
Geographical Analysis of Physicians With Questionable Billing 
We determined the locations of physicians with questionable billing in 
2011.  To do this, we identified each physicians Core Base Statistical Area 
(CBSA) on the basis of the ZIP Code listed on the physicians claims for 
electrodiagnostic tests.36  CBSAs may be categorized as metropolitan or 
micropolitan.  We determined the percentage of physicians in each 
metropolitan area who had questionable billing and identified the 
metropolitan areas with the highest concentrations of physicians with 
questionable billing. 
In metropolitan areas with the highest number of physicians with 
questionable billing, we calculated the total number of physicians, the 
percentage of physicians with questionable billing, and the Medicare 
 
34 When a physician has an  unusually high  percentage of  beneficiaries for whom at least  
three physicians billed Medicare for electrodiagnostic tests, this may indicate that 
physicians have worked together to share beneficiaries.  Beneficiary-sharing is a 
common fraud  scheme and may involve cooperation among managers, physicians, and 
marketers to solicit beneficiaries or beneficiary Medicare numbers.   
35  We ensured that our threshold met or exceeded the highest total number of tests 
recommended by  AANEM, which was  14  tests.  

36 A CBSA is a region around an  urban center that has at least 10,000  people.   U.S.
  
Census Bureau, Metropolitan and Micropolitan Statistical  Areas. Accessed at 

http://www.census.gov/population/metro/ on January 31, 2013.   

Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              9  
   
   
payments to physicians with questionable billing in these areas.  
Additionally, for each metropolitan area with physicians with questionable 
billing, we identified the number of physicians with at least three measures 
of questionable billing and the Medicare payments to these physicians. 
Limitations 
We did not conduct a medical record review to determine whether the 
services we identified as being associated with questionable billing were 
inappropriate or fraudulent. Further, these characteristics are not intended 
to be a comprehensive set of measures for identifying questionable billing 
for electrodiagnostic tests. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              10 
   
   
FINDINGS 
In 2011, 4,901 physicians had questionable billing for 
Medicare electrodiagnostic tests totaling $139 million 
A total of 4,901 physicians met or exceeded the threshold for at least one 
measure of questionable billing, representing 23 percent of the 
21,663 physicians who billed for electrodiagnostic services in 2011.  
Table 1 shows the number and percentage of physicians by the number of 
questionable billing measures for which physicians exceeded thresholds.  
These questionable billings accounted for 31 percent ($139 million of 
$486 million) of the Medicare payments for electrodiagnostic tests in 
2011.   
Of the physicians with questionable billing, 49 percent (2,387 of 4,901) 
were neurologists and physiatrists who, have special training in 
electrodiagnostic medicine, and therefore may see more patients who 
require electrodiagnostic testing, and may bill for more of these tests.  The 
remaining 51 percent (2,514 of 4,901) were physicians in other specialties.  
Physicians with questionable billing in other specialties largely 
represented internal medicine, family practice, orthopedic surgery, and 
podiatry (i.e., recognized by AANEM as specialties that are generally not 
considered to have expertise in electrodiagnostic medicine).  Appendix A  
shows the number and percentage of physicians with questionable billing 
in each specialty.   
Overall, 13 percent (644 of 4,901) of physicians with questionable billing 
exceeded the thresholds for two or more measures of questionable billing.  
Appendix B shows the number and percentage of physicians by the 
number of measures of questionable billing for which physicians exceeded 
thresholds in each specialty group (i.e., neurologists and physiatrists, and  
physicians in other specialties). 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              11 
   
   
Table 1. Number and Percentage of Physicians Who Exceeded Thresholds 
for Questionable Billing, 2011 
Number of Measures of  
Questionable Billing for 
Which Physicians  Number of   Percentage of  
Exceeded Thresholds   Physicians   Physicians  
0  16,762   77%  
1  4,257   20%  
2  572  3%  
3  72  <1%  
4 or more   0  <1% 
   Total*  21,663   100%  
*The percentage  column sum does not equal total because of rounding. 

Source:  OIG analysis of 2011 NCH Carrier file. 
 
 
For each measure of questionable billing, Table 2 shows the total number 
of physicians who met or exceeded the threshold for unusually high billing 
and the associated Medicare payments.  Appendix C shows the median 
(i.e., the value at which 50 percent of all physicians billed for that 
measure); the threshold that indicated unusually high billing; the range of 
unusually high billing; and the number of physicians in each specialty 
group with unusually high billing. 
Table 2. Physicians With Unusually High Billing by Each Measure of 
Questionable Billing, 2011* 
 
Physicians With Unusually  High  
 
Billing  
 
     
     
  Total Number of   
  Physicians   
  Meeting or   
  Exceeding  Total Medicare 
Measure of Questionable Billing  Threshold   Payments  
High percentage of electrodiagnostic test claims with modifiers   2,208    $47 million  
   Modifier 59  2,156  $46 million 
   Modifier 25    52   $1 million 
High percentage of electrodiagnostic test claims from all billing for     
 
Part B items and services  1,155  $61 million  
High percentage of electrodiagnostic test claims that did not include     
both an NCT and needle EMG test   907  $19 million  
High average number of miles between physicians and beneficiaries     
locations  700  $15 million  
High percentage of beneficiaries for whom at least three physicians     
billed for electrodiagnostic tests  346  $ 3 million  
High average number of electrodiagnostic test claims for the same     
beneficiary on the same day  334  $20 million 
         Total**    4,901   $139 million  
* The medians, thresholds, and range of billing for each measure  of questionable billing, by specialty group, are listed in Appendix C. 

** The sums of the  numbers do not equal the totals because some physicians had multiple measures of questionable billing. 
   
Source:  OIG analysis of 2011 NCH Carrier File. 

 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              12 
   
   
In 2011, 2,208 physicians billed for an unusually high 
percentage of electrodiagnostic tests using modifiers 
In 2011, 2,208 physicians billed for an unusually high percentage of 
electrodiagnostic tests using modifiers 59 and/or 25 on their claims.  These 
claims accounted for $47 million of the 2011 payments for 
electrodiagnostic tests.  Billing for a high percentage of electrodiagnostic 
tests using modifiers may indicate that a physician is using the modifiers 
to increase payments inappropriately.    
A total of 2,156 physicians billed for an unusually high percentage of 
electrodiagnostic tests using modifier 59 (i.e., billing for a significant, 
separately identifiable non-E/M service by the same physician on the same  
day as another procedure). Of all these physicians, 19 percent 
(405 of 2,156) always billed for electrodiagnostic tests using modifier 59.37  
A total of 52 physicians billed for an unusually high percentage of 
electrodiagnostic tests using modifier 25 (i.e., billing for a significant, 
separately identifiable E/M service by the same physician on the same day 
as another procedure). Of 21,663 physicians who billed for 
electrodiagnostic tests in 2011, these 52 were the only physicians who 
billed for electrodiagnostic tests using modifier 25.38   
In 2011, 1,155 physicians billed for an unusually high 
percentage of electrodiagnostic tests 
In 2011, 1,155 physicians in specialties other than neurology or physiatry 
billed for an unusually high percentage of electrodiagnostic tests 
compared to all of their billing for Part B items and services.  These 
claims accounted for $61 million of the 2011 payments for 
electrodiagnostic tests. For example, 23 physicians billed only for 
electrodiagnostic tests and no other Part B items and services in 2011, 
totaling $685,000.39  For physicians in specialties other than neurology and 
physiatry, a high percentage of billing for electrodiagnostic tests may 
indicate that the physicians are submitting claims  for services that were 
not medically necessary or were never provided to the beneficiary.  
 
37 The three specialties with the highest numbers of physicians who always billed  using  
modifier 59  were internal medicine (89 of  405), neurology  (78 of  405), and family  
practice (61 of 405).  
38 The majority of physicians  who  billed  for electrodiagnostic test claims using 
modifier 25  were  neurologists (30 of  52) and physiatrists (17  of 52). 
39 These physicians  represented the following specialties: physical therapist in  private 
practice (13  of  23); independent diagnostic testing  facility (5 of 23); family practice 
(2 of  23);  neurosurgery;  pediatric medicine, and single or  multispecialty  clinic or group  
practice. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              13 
   
   
In 2011, 907 physicians billed for an unusually high percentage 
of electrodiagnostic tests that did not include both an NCT and 
needle EMG test 
In 2011, 907 physicians billed for an unusually high percentage of 
electrodiagnostic tests that did not include both an NCT and a needle 
EMG test. These claims accounted for $19 million of the 2011 payments 
for electrodiagnostic tests. Typically, when NCTs are used alone, without 
integrating needle EMG findings, the results may be misleading, 
potentially causing important diagnoses to be missed.40    
All of the physicians whom we identified as having an unusually high 
percentage of electrodiagnostic tests that did not include both an NCT and 
a needle EMG test were neurologists or physiatrists.  None of the 
physicians in other specialties were identified statistically as having 
unusually high billing because they almost always billed for 
electrodiagnostic tests without having both an NCT and a needle EMG test 
on the same claim; the median for such physicians was 85 percent.  These 
physicians represented approximately $72 million in payments.41 Because 
there was no distribution in billing for this measure of questionable billing 
among non-neurologist and nonphysiatrist physicians, we identified no 
physicians in this category as billing for unusually high percentages of 
electrodiagnostic tests that did not include both an NCT and needle EMG  
test. However, this billing pattern among non-neurologist and 
nonphysiatrist physicians raises concerns. 
In 2011, 700 physicians billed for electrodiagnostic tests for 
beneficiaries from locations an unusually high average 
number of miles away  
In 2011, 700 physicians billed for electrodiagnostic tests for beneficiaries 
who resided an unusually high average number of miles from the 
physicians practice locations.  These claims accounted for $15 million of 
the 2011 payments for electrodiagnostic tests.  For example, we found that 
one general practitioner in Indianapolis, Indiana, billed for an  
electrodiagnostic test for a beneficiary who resided nearly 2,000 miles 
away, in McKinleyville, California. This physicians 27 other beneficiaries 
resided an average of 1,785 miles away.42   
A high average number of miles between physicians and beneficiaries  
locations may indicate that a physician is billing for electrodiagnostic tests 
that were not medically necessary or were never provided to the 
 
40 NCTs performed without a needle EMG may be acceptable for some diagnoses.   
41 The Tukey method  requires a distribution  or variability in billing to identify outliers.   
42 Nearly all (26  of 28) of these beneficiaries resided in California. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              14 
   
   
beneficiary.  Further,  beneficiaries with conditions that may cause nerve 
damage, such as diabetes or carpal tunnel syndrome, would not be 
expected to travel such long distances for electrodiagnostic tests.   
In 2011, 346 physicians billed for an unusually high percentage 
of beneficiaries for whom at least three physicians also billed 
for electrodiagnostic tests  
In 2011, 346 physicians billed for an unusually high percentage of 
beneficiaries for whom at least three physicians also billed for 
electrodiagnostic tests.   These claims accounted for $3 million of the 
2011 payments for electrodiagnostic tests. 43   When multiple physicians 
bill for the same services provided to the same beneficiary, there is 
potential for fraud (i.e., beneficiary-sharing).  For example, 100 percent of 
the beneficiaries for 28 physicians had electrodiagnostic test claims from 
at least 3 physicians in 2011.44    
In 2011, for about 95 percent of beneficiaries, one physician submitted 
claims for their electrodiagnostic tests.  For about 5 percent of 
beneficiaries, two physicians submitted claims for their electrodiagnostic 
tests. For less than 1 percent of beneficiaries, three or more physicians 
submitted claims for their electrodiagnostic tests.  In the case of one 
beneficiary, nine different physicians billed Medicare for this individuals  
electrodiagnostic tests in 2011. 
In 2011, 334 physicians billed for an unusually high average 
number of electrodiagnostic tests for the same beneficiary on 
the same day 
In 2011, 334 physicians billed for an unusually high average number of 
electrodiagnostic tests for the same beneficiary on the same day.45 These 
claims accounted for $20 million of the 2011 payments for 
electrodiagnostic tests. For example, 6 physicians billed for an average of  
32 electrodiagnostic tests for the same  beneficiary on the same day, almost 
5 times the median number of 7 electrodiagnostic tests.46  Billing for 
multiple electrodiagnostic tests for the same beneficiary on the same day 
 
43  Thirty providers who had an unusually  high  percentage of beneficiaries for  whom  other 
providers billed Medicare for electrodiagnostic tests also had an  unusually high average 
number of  miles  between their and beneficiaries locations. 
44 The majority of these providers had the following specialties:  family practice 
(6 of  28), internal medicine (6  of 28), and orthopedic surgery (4  of 28).  
45 Sixty-seven physicians  who  billed for an unusually high  percentage  of  
electrodiagnostic test claims using modifiers also  billed for an  unusually high average 
number of electrodiagnostic test claims for the same beneficiary on the same day.   
46 The six  physicians represented the following specialties:  family practice, internal 
medicine, nurse practitioner, and physician assistant. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              15 
   
   
may indicate that a physician is billing for electrodiagnostic tests that were 
not medically necessary or were never provided to the beneficiary.    
Approximately 20 percent of physicians with questionable 
billing in 2011 received a CBR on the basis of their 2010 billing 
for electrodiagnostic tests  
CMS issues CBRs that are designed to compare a providers billing and 
payment patterns to those of his or her peers across the Nation.  
Additionally, CBRs are intended to proactively educate providers and help 
them identify and prevent future errors in their billing practices.   
In late 2011, CMS and its contractors issued CBRs to 4,241 physicians 
who billed for NCTs and needle EMGs in 2010.  The CBR analysis 
measures include some of the same analysis and measures of questionable 
billing that we used in this report.  The primary differences, however, are 
that CMS typically excludes neurologists and physiatrists from its 
analysis, and that its measures are not intended to identify physicians who 
had unusually high billing.47   
A total of 1,095 physicians who received a CBR in 2011 on the basis of 
their 2010 billing also had questionable billing for electrodiagnostic tests 
in 2011, totaling approximately $34 million.  The remaining 78 percent 
(3,806 of 4,901) of physicians whom we identified as having questionable 
billing did not receive a CBR in 2011.48   Table 3 shows the number of 
physicians with questionable billing, whether they received CBRs, and the 
questionable Medicare payments. 
   
 
47 Although CMSs methods for creating CBRs for electrodiagnostic tests state that it 
excludes neurologists and physiatrists, we  found that 12  physicians in the neurologist and  
physiatrist specialty group who had  questionable billing received CBRs.  
48 These physicians may not  have  billed for electrodiagnostic tests in  2010, so they would  
not have received a CBR in  2011. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              16 
   
   
Table 3. Physicians With Questionable Billing and CBRs in Each Specialty  
Group, 2011  
Number of        
Physicians    Number of    
  With     Physicians With    
  Questionable     Questionable    
Billing and  Medicare  Billing and no  Medicare 
CBRs   Payments*   CBRs   Payments  
Physicians in Other         
Specialties   1,083   $33 million   1,429   $37 million  
Neurologists and          
Physiatrists  12  $786,512   2,377   $68 million 
 Total   1,095   $34 million   3,806   $105 million  
* The column sum does not equal total because of rounding.  
Source: OIG analysis of 2011 NCH Carrier File. 
 
Thirty-eight percent of physicians with questionable 
billing for electrodiagnostic tests were in
10 metropolitan areas 
Certain metropolitan areas had a higher percentage of physicians with 
questionable billing for electrodiagnostic tests than did the Nation as a 
whole, which had 23 percent. Physicians with questionable billing for 
electrodiagnostic tests in these 10 metropolitan areas made up 38 percent 
(1,883 of 4,901) of all physicians with questionable billing.  The 
New York, Los Angeles, and Houston areas had the highest Medicare 
payments associated with questionable billing.  Specifically, Medicare 
paid $27 million associated with questionable billing to 737 physicians in 
the New York area.  Medicare paid approximately $12 million associated 
with questionable billing to 219 physicians in the Los Angeles area, and 
approximately $6 million associated with questionable billing to 
156 physicians in the Houston area. 
Table 4 shows for 10 metropolitan areas the number of physicians with 
questionable billing, the total number of physicians, the percentage of 
physicians with questionable billing, and the Medicare payments for 
physicians with questionable billing.  Appendix D includes the number of 
physicians with questionable billing in these metropolitan areas 
categorized by specialty group. 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              17 
   
   
Table 4. Metropolitan Areas With the Highest Number of Physicians With 
Questionable Billing, 2011 
Total Number of  
Physicians With   Percentage of   Questionable 
Metropolitan   Questionable   Total Number of   Physicians With    Medicare 
Area   Billing   Physicians   Questionable Billing     Payments 
         
New York, NY   737  2,745   27%   $26,625,059  
         
Los Angeles, CA  219  695  32%   $11,581,976 
         
Houston, TX   156  395  39%   $5,983,651 
         
Miami, FL  193  566  34%   $4,945,350 
         
Dallas, TX   109  345  32%   $3,168,436 
         
Detroit, MI   98  483  20%   $3,717,991 
         
Chicago, IL  97  644  15%   $3,233,386 
         
Washington, DC   96  403  24%   $1,995,174 
         
Phoenix, AZ   91  306  30%   $3,091,317 
 
Baltimore, MD  87  277  31%   $1,674,583  
Nation  4,901   21,663   23%   $139 million  
 
Source: OIG analysis of physician data for electrodiagnostic tests, 2011.  
 
Additionally, within the group of 4,901 physicians who met or exceeded 
the threshold for at least one measure of questionable billing, 72 
physicians met or exceeded the thresholds for three measures of 
questionable billing.  Medicare paid $4 million associated with 
questionable billing to such physicians.  The metropolitan areas with the 
highest numbers of such physicians were Las Vegas, Nevada; New York, 
New York; and Baltimore, Maryland; in these three areas, these physicians  
received a total of $880,000 associated with questionable billing.  
Appendix E lists the geographical areas of physicians who met or 
exceeded the thresholds for three measures of questionable billing in 2011.   
Appendix F lists the geographical areas of the top 10 physicians with 
questionable billing in 2011.     
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              18 
   
   
CONCLUSION AND RECOMMENDATIONS 
We found that 4,901 physicians had questionable billing for 
electrodiagnostic tests with Medicare payments totaling $139 million in 
2011.  While there may be legitimate reasons for some of this billing, all 
of these physicians warrant further scrutiny. The majority of these 
physicians had an unusually high percentage of claims with modifiers, 
which allow physicians to receive payments for services that are typically 
not separately payable. Previous OIG studies also found that some  
physicians and providers use modifiers to increase payments 
inappropriately. For example, a 2005 OIG evaluation found that 
$59 million was paid improperly for claims using modifier 59.  Further, 
many of the non-neurologist and nonphysiatrist physicians whom we 
identified as having questionable billing had an unusually high percentage 
of claims for electrodiagnostic tests compared to their claims for other 
Part B items and services.  Finally, physicians in the New York, 
Los Angeles, and Houston areas had the highest total questionable billing 
for Medicare electrodiagnostic tests in 2011. 
Our findings further indicate vulnerabilities in the monitoring of Medicare 
billing for electrodiagnostic tests.  We found that approximately 
20 percent of the physicians with questionable billing for electrodiagnostic 
tests received CBRs in 2011 on the basis of their 2010 electrodiagnostic 
test billing. Further, nearly half of the physicians whom we identified as 
having questionable billing were neurologists and physiatrists.  However, 
CMS typically does not provide CBRs on electrodiagnostic testing to 
neurologists and physiatrists. 
We recommend that CMS: 
Increase monitoring of billing for electrodiagnostic tests 
CMS should instruct its contractors (e.g., Medicare Administrative 
Contractors, Zone Program Integrity Contractors) to monitor the billing of 
electrodiagnostic tests using measures of questionable billing similar to 
those we incorporated into this study.  CMS should develop thresholds for 
these measures and instruct its contractors to conduct additional reviews of 
physicians who exceed them.  For example, CMS could use AANEM 
recommendations for the maximum number of electrodiagnostic tests that 
should be performed to develop edits on the number of tests billed.  CMS 
could also include these measures of questionable billing in its 
fraud-prevention system. Finally, CMS should use comparative billing 
reports to identify and monitor all physiciansincluding neurologists and 
physiatristswith unusually high billing for electrodiagnostic tests.  
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              19 
   
   
Provide additional guidance and education to physicians 
regarding electrodiagnostic tests 
CMS should update its guidance and provide additional education to 
physicians who provide electrodiagnostic tests.  As part of this effort, 
CMS should educate physicians on industry guidance regarding  providing 
NCTs in conjunction with needle EMGs for establishing reliable and 
accurate diagnoses. 
Take appropriate action regarding physicians whom we  
identified as having inappropriate or questionable billing 
In a separate memorandum, we will send the claims data for physicians 
with inappropriate or questionable billing to CMS for appropriate action. 
 
 
 
 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              20 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS partially concurred with our first two recommendations and 
concurred with the third one. With regard to the first recommendation, 
CMS partially concurred and stated that it will evaluate the cost-
effectiveness of implementing new thresholds for questionable billing and 
conducting medical record reviews of physicians who exceed them.  CMS 
also provided information about its efforts to monitor Medicare billing for 
electrodiagnostic tests.  Specifically,  CMS will share this report with its 
Recovery Auditors for possible review and overpayment recovery.  CMS 
will also consider including a model that monitors for unusually high 
billing for electrodiagnostic tests in its Fraud Prevention System.  Finally,  
CMS will develop CBRs on electrodiagnostic testing that include 
neurologists and physiatrists. 
With regard to the second recommendation, CMS partially concurred and 
stated that it established revised values for new codes that bundle needle 
EMG and NCT codes, which has resulted in simplified coding and savings 
to the Medicare program for these services.  CMS noted that it is 
prohibited from providing guidance on the practice of medicine to 
physicians and, therefore, it may be a violation to emphasize the 
importance of providing NCTs in conjunction with needle EMGs.  In 
response to CMSs comments, we clarified this recommendation to state 
that CMS should educate physicians on industry guidance regarding 
performing and billing for these services together.  We are not 
recommending that CMS provide guidance on the practice of medicine to 
physicians. 
With regard to the third recommendation, CMS concurred and will instruct 
the Supplemental Medical Review Contractor to review some or all of the 
physicians identified in this report.   CMS will also ask these contractors to 
determine which of the seven questionable billing measures were the best 
predictors of improper payments.  Finally, any suspicions of potential 
fraud will be referred to the appropriate Zone Program Integrity 
Contractor. 
We support CMSs efforts to address these issues and encourage it to 
continue making progress.  For the full text of CMSs comments, see 
Appendix G. 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              21 
   
   
APPENDIX A 
Number and Percentage of Medicare Physicians With 
Questionable Billing for Electrodiagnostic Tests in Each 
Specialty, 2011 
  Number of     Percentage of  
 
  Physicians With     Physicians With  
  Questionable   Number of   Questionable  
    Billing in Each   Physicians in  Billing in Each  
Specialty   Specialty   Each Specialty   Specialty  
Neurology  1696   7050   24%  
Physiatry  693  4245   16%  
Internal Medicine  594  2742   22%  
Family Practice  461  2144   22%  
Orthopedic Surgery  211  1115   19%  
Podiatry  163  550  30%  
Interventional Pain Management   111  344  32%  
General Practice  82  229  36%  
Neurosurgery  75  192  39%  
Physician Assistant  70  249  28%  
Physical Therapist in Private Practice   68  134  51%  
Independent Diagnostic Testing Facility (IDTF)  67  86  45% 
Pain Management  61  150  41%  
Nurse Practitioner  59  266  22%  
Hand Surgery  47  135  35%  
Anesthesiology  40  170  24%  
Cardiology   37  206  18%  
Endocrinology  37  180  21%  
Rheumatology  36  284  13%  
Emergency Medicine  36  102  35%  
Nephrology  31  68  46%  
General Surgery  22  111  20%  
Pediatric Medicine   21  42  50%  
Otolaryngology  20  354  6%  
Psychiatry   19  30  63%  
Diagnostic Radiology  18  46  39%  
Colorectal Surgery  (formerly Proctology)  16  92  17%  
Pulmonary Disease  16  45  36%  
Plastic and Reconstructive Surgery  14  55  25%  
Osteopathic Manipulative Medicine  11  30  37%  
Neuropsychiatry   11  18  61%  
Obstetrics/Gynecology  9  24  38%  
Gastroenterology  7  27  26%  
Hematology/Oncology  6  20  30%  
Urology  5  17  29%  
(continued on next page)  
 
     
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                            22 
   
   
APPENDIX A  (CONTINUED)  
Number and Percentage of Medicare Physicians With 
Questionable Billing for Electrodiagnostic Tests in Each 
Specialty, 2011 
Number of   Percentage of  
Physicians With   Physicians With  
Questionable   Number of   Questionable  
Billing in Each   Physicians in  Billing in Each  
Specialty   Specialty   Each Specialty   Specialty  
Infectious Disease  5  12  42%  
Vascular Surgery  5  13  38%  
Geriatric Medicine  4  18  22%  
Allergy/Immunology  3  9  33%  
Ophthalmology   2  4  50%  
Pathology  2  4  50%  
Sports Medicine  2  6  33%  
Thoracic Surgery  2  3  67%  
Occupational Therapist in Private Practice  2  4  50%  
Oral Surgery (Dentists Only)   1  3  33%  
Nuclear Medicine  1  1  100%  
Single or Multispecialty Clinic or Group Practice  1  4  25%  
Peripheral Vascular Disease  1  1  100%  
Addiction Medicine  1  2  50%  
Critical Care (Intensivists)   1  3  33%  
Dermatology  0  1  0%  
Audiologist (Billing Independently)   0  4  0%  
Clinical Laboratory  (Billing Independently)  0  2  0% 
Preventive Medicine  0  4  0%  
Maxillofacial Surgery   0  1  0% 
Certified Clinical Nurse Specialist   0  2  0%  
Medical Oncology  0  2  0%  
Surgical Oncology  0  6  0%  
Radiation Oncology   0  1  0%  
Interventional Radiology  0  1  0% 
   Total   4,901   21,663   23%  
Source:  OIG analysis of physician data for electrodiagnostic tests, 2011. 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                            23 
   
   
APPENDIX B 
Number and Percentage of Medicare Physicians Who 
Exceeded Thresholds of Questionable Billing for 
Electrodiagnostic Tests by Specialty Group, 2011 
Number of Measures for 
Which Physicians Exceeded 
Percentage of  
Specialty Group   Thresholds of Questionable  Number of Physicians  
Physicians  
Billing for Electrodiagnostic 
Tests  
0  8,903   79%  
1  2,078   18%  
Neurologists and  
2  265  2%  
Physiatrists 
3  46  <1%  
  
4 or more   0  0% 
 Total*  11,292   100%  
0  7,859   76%  
1  2,179   21%  
Physicians in Other  2  307  3%  
Specialties   3  26  <1%  
4 or more   0  0% 
 Total*  10,371   100%  
* The sums of the percentages in  the final column does not equal total because of rounding. 
Source:  OIG analysis of physician data for electrodiagnostic tests, 2011. 
 
 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              24 
   
   
APPENDIX C 
Physicians With Unusually High Billing by Each Measure of 
Questionable Billing, 2011 
Table C-1. Neurologists and Physiatrists With Unusually High Billing by  
Each Measure of Questionable Billing, 2011 
     
     
     
     
    Neurologists and Physiatrists With Unusually  High Billing  
           
           
          Number of  
          Physicians 
Measure of  Questionable      Range of  Medicare  Exceeding 
Billing   Median  Threshold   Billing   Billing   Threshold  
High percentage of 
      $29.9 million  1,047  
electrodiagnostic test claims 
         
with modifiers 
2%   48%   48% to 100%   $29 million   1,000  
Modifier 59   0%   0%   <1% to 12%   $994,000   47  
Modifier 25**  
High percentage of 
electrodiagnostic test claims 
-- --  --  --  -- 
from all billing for Part B items 
and services*  
High percentage of 
         
electrodiagnostic test claims 
         
that did not include both an NCT 
8%   61%   61% to 100%   $18.7 million  907 
and needle EMG test 
High average number of miles           
between physicians and           
beneficiaries locations  116  321  321 to 2,961   $11.7 million  358 
High percentage of beneficiaries           
for whom at least three           
physicians billed Medicare for           
electrodiagnostic tests  2%   7%   7% to 100%   $ 1.5 million   256 
High average number of           
electrodiagnostic test claims on           
the same beneficiary on the           
same day***   8  14  14 to 30   $15.9 million  181 
Total ****  $68.9 million   2,389  
*Because some neurologists and physiatrists may  reasonably bill for electrodiagnostic tests and have no other billing for Part 
B items and services, we did not include neurologists and physiatrists in the analysis  for this characteristic.  
**The median and threshold are 0 percent for this characteristic because only 47 of 11,292 neurologists and physiatrists 
used modifier 25 on at least 1 of their 2011 electrodiagnostic test claims.  All 47 of these physicians were identified using the 
Tukey method as having an unusually high percentage.  
*** Under the Tukey method, an outlier is a number greater than the 75th percentile plus 1.5 times the interquartile range.  For 
this characteristic of questionable billing, the Tukey method yielded a threshold number of 13 tests.  However, because 
AANEM sets at 14 the maximum number of tests considered reasonable to make a diagnosis, we used a threshold of 
14 tests. 
****The sums of the columns do not equal totals because some neurologists and physiatrists had multiple measures of 
questionable billing.  
Source: OIG analysis of physician data for electrodiagnostic tests, 2011.  
 
   
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              25 
   
   
APPENDIX C (CONTINUED)  
Physicians With Unusually High Billing by Each Measure of 
Questionable Billing, 2011 
Table C-2. Physicians in Other Specialties With Unusually High Billing by  
Each Measure of Questionable Billing, 2011 
     
     
     
    Physicians in Other Specialties With Unusually High Billing  
           
           
          Number of  
          Physicians 
      Range of  Medicare  Exceeding 
Measure of Questionable Billing  Median  Threshold   Billing   Billing   Threshold  
High percentage of 
      $17 million   1,161  
electrodiagnostic test claims with 
         
modifiers 
0%   42%   42% to 100%   $17 million   1,156  
Modifier 59  
0%   0%   <1% to 25%   $16,000   5 
Modifier 25*  
High percentage of 
         
electrodiagnostic test claims from 
         
all billing for Part B items and 
1%   13%   13% to 100%   $60.7 million  1,155  
services  
High percentage of 
   
electrodiagnostic test claims that 
    --  --  -- 
did not include both an NCT and 
85%   100%  
needle EMG test ** 
High average number of miles           
between physicians and           
beneficiaries locations  111  335  335 to 2,541   $3.4 million   342 
High percentage of beneficiaries           
for whom at least three physicians           
billed Medicare for           
electrodiagnostic tests  6%   28%   28% to 100%   $1.3 million   90 
High average number of           
electrodiagnostic test claims for           
the same beneficiary on the same           
day  7  19  19 to 32   $4.1 million   153 
         Total ***   $69.9 million   2,512  
*The median and threshold are 0  percent for this characteristic because only 5 of 10,371 physicians with other specialties 
used modifier 25 on their 2011 electrodiagnostic test claims.  All five of these physicians were identified using the Tukey  
method as having an unusually high percentage.  
 
** The Tukey method requires a distribution or variability in billing to identify unusual behavior.  Because there was no 
distribution in billing for this measure of questionable billing among physicians in this  specialty group (i.e., they  almost always  
billed for NCTs without needle EMGS), no physicians were identified as billing for unusually high percentages of NCTs 
without needle EMGs. 
*** The sums of the columns do not equal total because some physicians in other specialties had multiple questionable billing 
characteristics.  
Source: OIG analysis of physician data for electrodiagnostic tests, 2011.  
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              26 
   
   
APPENDIX D 
Metropolitan Areas With the Highest Number of Physicians 
With Questionable Billing by Specialty Group, 2011 
Number of   Number of  
Neurologists and  Physicians in Other  Total Number of  
Physiatrists with   Specialties with  Physicians With  
Metropolitan Area  Questionable Billing   Questionable Billing   Questionable Billing  
       
New York, NY  243  494  737 
       
Los Angeles, CA  114  105  219 
       
Miami, FL  75  118  193 
       
Houston, TX   62  94  156 
       
Dallas, TX   79  30  109 
       
Detroit, MI   44  54  98 
       
Chicago, IL  57  40  97 
       
Washington, DC   47  49  96 
       
Phoenix, AZ   45  46  91 
   
Baltimore, MD  41  46  87 
Total   807  1,076   1,883 
   
   Nation   2,387  2,514  4,901  
Source:  OIG analysis of physician data for electrodiagnostic tests, 2011. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              27 
   
   
APPENDIX E 
Geographical Areas of Physicians With Three Measures of 
Questionable Billing, 2011 
 
Number of   Percentage of  
Physicians With   Physicians With  
Multiple Measures  Multiple Measures 
Questionable   of Questionable   of Questionable  
Geographical Area  Medicare Billing   Billing   Billing  
 
Las Vegas-Paradise, NV  $420,083   8  11.11%  
8.33%  
New  York-Northern New Jersey-Long Island, NY-NJ-PA  $351,020   6 
6.94%  
Baltimore-Towson, MD  $108,039   5 
5.55%  
Miami-Fort Lauderdale-Pompano Beach, FL   $34,258   4 
4.17% 
Boston-Cambridge-Quincy, MA-NH  $95,361   3 
4.17% 
Fort Collins-Loveland, CO  $53,441   3 
4.17% 
Phoenix-Mesa-Glendale, AZ  $3,439   3 
2.78% 
Denver-Aurora-Broomfield, CO  $406,247   2 
2.78% 
Oxnard-Thousand Oaks-Ventura, CA  $192,849   2 
2.78% 
Jamestown-Dunkirk-Fredonia, NY   $43,838   2 
2.78% 
Detroit-Warren-Livonia, MI  $32,639   2 
2.78% 
Los Angeles-Long Beach-Santa Ana, CA   $16,150   2 
2.78% 
San Diego-Carlsbad-San Marcos, CA  $11,482   2 
2.78% 
Houston-Sugar Land-Baytown, TX   $9,451   2 
1.39%  
Cape Coral-Fort Myers, FL   $698,550   1 
1.39%  
Dallas-Fort Worth-Arlington, TX   $548,708   1 
1.39% 
New Orleans-Metairie-Kenner, LA  $350,562   1 
1.39% 
Lansing-East Lansing, MI  $142,734   1 
1.39% 
Washington-Arlington-Alexandria, DC-VA-MD-WV   $136,775   1 
1.39% 
Hagerstown-Martinsburg, MD-WV   $54,710   1 
1.39% 
Anchorage, AK   $32,034   1 
1.39% 
St. Louis, MO-IL   $29,132   1 
1.39% 
Austin-Round Rock-San Marcos, TX  $28,814   1 
1.39% 
Trenton-Ewing, NJ  $25,832   1 
1.39% 
Topeka, KS   $23,470   1 
1.39% 
Nashville-Davidson--Murfreesboro-Franklin, TN   $21,965   1 
1.39% 
New Haven-Milford, CT   $18,538   1 
(continued on next page) 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              28 
   
   
APPENDIX E (CONTINUED)  
Geographical Areas of Physicians With Three Measures of 
Questionable Billing, 2011 
Number of   Percentage of  
Physicians With   Physicians With  
Multiple Measures  Multiple Measures 
Questionable   of Questionable   of Questionable  
Geographical Area  Medicare Billing   Billing   Billing  
1.39% 
Louisville-Jefferson County, KY   $12,007   1 
1.39% 
Lake Havasu City-Kingman, AZ   $11,969   1 
1.39% 
Toledo, OH   $9,504   1 
1.39% 
Flint, MI  $6,793   1 
1.39% 
McAllen-Edinburg-Mission, TX  $3,766   1 
1.39% 
Chicago-Naperville-Joliet, IL-IN-WI   $2,508   1 
1.39% 
San Juan-Caguas-Guaynabo, PR   $1,718   1 
1.39% 
Bloomsburg-Berwick, PA  $1,062   1 
1.39% 
Minneapolis-St. Paul-Bloomington, MN-WI   $854   1 
1.39% 
San Angelo, TX   $534   1 
1.39% 
Somerset, PA  $448   1 
1.39% 
Brownsville-Harlingen, TX   $430   1 
1.39% 
Rural   $88,485   1 
 
Total*  $4 million   72  100%  
*The sum of the percentages in the final column does not equal the total because of rounding.  
Source: OIG analysis of physician data for electrodiagnostic tests, 2011. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              29 
   
   
 
APPENDIX F 
Geographical Areas of Top 10 Physicians With Questionable 
Billing, 2011 
Questionable  
Physician  Medicare  
Number  Geographical Area  Billing  
Physician 1  Los Angeles-Long Beach-Santa Ana, CA   $3,103,642  
 
 
Physician 2  Miami-Fort Lauderdale-Pompano Beach, FL   $900,513  
 
 
Physician 3  New  York-Northern New Jersey-Long Island, NY-NJ-PA  $769,644  
 
 
Physician 4  Brownwood, TX   $732,342  
 
Physician 5  Cape Coral-Fort Myers, FL   $698,550  
 
 
Physician 6  Los Angeles-Long Beach-Santa Ana, CA   $690,872  
 
Physician 7  New  York-Northern New Jersey-Long Island, NY-NJ-PA  $597,269  
 
Physician 8  Bakersfield-Delano, CA   $576,119  
 
Physician 9  Detroit-Warren-Livonia, MI  $564,589  
 
 
Physician 10  New  York-Northern New Jersey-Long Island, NY-NJ-PA  $558,112 
                                 Source:  OIG analysis of physician data for electrodiagnostic tests, 2011. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              30 
  APPENDIX G 
Agency Comments 
(,j. 
/<,J.IJ.VIC(J'\
DEPARTMENT OF IlEALTil & HUMAN SERVICES  Centers for Medicare &Medicaid Services 
Administrator 
Washington. DC 20201 
DATE:  MAR 11 l ~l~ 
TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Murilyn 1ia".enner 

AdmirtlstMtot 

SUBJECT: 	 Office of the Inspector General (OIG) Draft Report: "Questionable Billingfor 
Medicare Electrodiagnostic Tests" (OEI-0412-00420) 
The Centers for Medicare &Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the above-mentioned OIG report. In 2011, Medicare paid approximately $486 
million to 21,700 physicians for electrodiagnostic tests billed on behalf of 877,000 beneficiaries. 
Electrodiagnostic tests arc used to evaluate patients who may have nerve damage. Recent 
investigations have found that electrodiagnostic testing is an area vulnerable to fraud, waste and 
abuse. CMS issues comparative billing reports to providers for avariety of services, including 
electrodiagnostic testing. Such reports are intended to proactively educate providers and identify 
and correct errors in their billing. 
The OIG developed seven measures of questionable billing on the basis of past OIG work and 
input from CMS staff. OIG analyzed Medicare 20 II electrodiagnostic test claims to identify 
physicians who had unusually high billing for at least one of these measures. 010 also 
determined whether physicians with questionable billing received comparative billing reports in 
20 II for electrodiagnostic testing. In addition, OIG identified the geographic areas with the 
largest amounts of questionable billing. 
The OIG found that in 20 II, 4,90 I physicians had questionable billing for Medicare 
electrodiagnostic tests totaling, $139 million. OIG also found that approximately 20 percent of 
these physicians received comparative billing reports, on the basis oftheir 20 I0  billing for 
electrodiagnostic tests. In addition, physicians in the New York, Los Angeles, and Houston 
areas had the largest total questionable billing for Medicare electrodiagnostic tests in 20 II. 
The 01G' s recommendations and CMS responses to those recommendations are discussed 
below. 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)  31   
   
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              32 
   
   
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              33 
   
   
 
 
 
 
 
 
 
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              34 
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office, and Jaime Durley, Deputy Regional Inspector General.  
Latrice Rollins served as lead analyst.  Central office staff who provided 
support include Scott Horning, Althea Hosein, Kevin Manley, Christine 
Moritz, and Mandy Walz.  
Questionable Billing for Medicare Electrodiagnostic Tests (OEI-04-12-00420)                                              35 
   
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: 
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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. 
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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.  
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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 
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enforcement authorities.