Department of Health and Human Services
 

OFFICE OF 

INSPECTOR GENERAL 

MEDICARE PART B BILLING
 

FOR ULTRASOUND
 

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 OIG’s 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. 
 

 

 

Δ EXECUTIVE SUMMARY 

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 

Medicare’s 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 
 

 

 

 

 

E X E CUTIVE S U MMAR Y 

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 Medicare’s 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 CMS’s comments. 

OEI-01-08-00100 PART B B ILLING FOR ULTRASOUND ii 
 

Δ TABLE OF CONTENTS 

EXECUTIVE SUMMARY ..................................... i 
 

INTRODUCTION ........................................... 1 
 

FINDINGS ................................................. 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 
 

RECOMMENDATIONS ..................................... 11 
 

Agency Comments and Office of Inspector General Response . . . 11 

APPENDIXES ............................................. 13 
 

A: Data Tables ........................................ 13 
 

B: Agency Comments ................................... 16 
 

ACKNOWLEDGMENTS .................................... 18 
 

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INTRODUCTION Δ INTRODUCTION 

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 Medicare’s 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. 

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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. 

1 
 

 

 

 

 

INTROD U C T I O N 

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 Medicare’s 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 

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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. 

2 
 

 

 

I NTRODUCTION 

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. 

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INTRODUCTION 
 

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 

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INTRODUCTION 

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. 

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6 45 CFR §§ 162.404 and 162.410. 

5 
 

INTRODUCTION 

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 President’s Council on Integrity and 

Efficiency and the Executive Council on Integrity and Efficiency (now 

Council of the Inspectors General on Integrity and Efficiency). 

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BANNER 2ND PAGE 

 

Δ 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, or 16 percent, of 

the $2.1 billion of Part B spending 

on ultrasound services. Similarly, 

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. 

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FINDINGS 

Nearly one in five ultrasound claims nationwide 

had characteristics that raise concern about 

whether the claims were appropriate 

In 2007, 3.2 million, or 19 percent, 

of Part B ultrasound claims had 

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. 

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FINDINGS 

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 

Questionable Characteristic 

High-Use Counties All Other Counties 

Number of 

Claims* 

Percentage of 

Claims* 

Number of 

Claims* 

Percentage of 

Claims* 

Claim lacked a prior service claim from the doctor who ordered the 

service 

Claim involved questionable use of ultrasound procedure 

codes** 

Claim was for one of more than five services provided to the same 

beneficiary on the same day by the same provider 

Claim was for a beneficiary who had ultrasound services billed for 

him or her by more than five providers in 2007 

Claim had missing or invalid data in the field that identifies the 

doctor who ordered the service 

331,993 

55,808 

33,458 

31,024 

7,097 

14.5% 

2.4% 

1.5% 

1.4% 

0.3% 

2,496,149 

231,928 

101,777 

12,966 

66,287 

16.9% 

1.6% 

0.7% 

0.1% 

0.5% 

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 Medicare National Claims History File, 2007.
 

Table 2: Allowed Charges for Ultrasound Part B Claims With Questionable Characteristics, 2007 

Questionable Characteristic 

High-Use Counties All Other Counties 

Allowed 

Charges* 

Percentage of 

Allowed 

Charges* 

Allowed 

Charges* 

Percentage of 

Allowed 

Charges* 

Claim lacked a prior service claim from the doctor who ordered the 

service 

Claim involved questionable use of ultrasound procedure 

codes** 

Claim was for one of more than five services provided to the same 

beneficiary on the same day by the same provider 

Claim was for a beneficiary who had ultrasound services billed for 

him or her by more than five providers in 2007 

Claim had missing or invalid data in the field that identifies the 

doctor who ordered the service 

$49,124,035 

$7,622,384 

$5,226,099 

$4,321,776 

$846,112 

14.6% 

2.3% 

1.6% 

1.3% 

0.3% 

$306,924,252 

$27,336,668 

$14,494,316 

$1,331,304 

$6,495,270 

17.2% 

1.5% 

0.8% 

0.1% 

0.4% 

Unduplicated total $62,403,039 18.6% $340,235,572 19.1% 

*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.
 

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FINDINGS 

Certain providers billed for a large number of 

ultrasound claims with questionable 

characteristics 

Although most of the 

104,598 providers who billed for 

ultrasound billed 20 or fewer 

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. 

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Δ RECOMMENDATIONS 

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 Medicare’s 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 

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RECOMMENDATIONS 

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 CMS’s comments. 

For the full text of CMS’s 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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Δ APPENDIX~A 

Table A-1: Ultrasound Covered Under Part B in High-Use Counties, 2007 

County and State 

Beneficiary 

Population 

Percentage of 

Beneficiaries 

Receiving 

Ultrasound 

Allowed Charges 

for Ultrasound 

Average Charges 

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 General (OIG) analysis of the Medicare National Claims History File, 2007. 

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APPENDIX-A 

Table A-2: Part B Claims Involving Questionable Use of Ultrasound Procedure 

Codes, 2007 

Number of 

Claims* 

Percentage 

of Claims* 

Number of 

Claims* 

Percentage 

of Claims* 

High-Use Counties All Other Counties 

Questionable Use 

76700 Ultrasound, abdominal, real time with image 

documentation, complete 

76705 Ultrasound, abdominal, limited (e.g., single organ, 

Claim involved a combination of procedures billed for the same 

beneficiary, on the same day, by the same provider: 

quadrant, followup) 

76830 Ultrasound, transvaginal documentation, complete 

76856 Ultrasound, pelvic (nonobstetric), real time with image 

911 0.04% 4,554 0.03% 

documentation, complete 

93925 Duplex scan of lower extremity arteries or arterial 

bypass grafts; complete bilateral study 

93978 Duplex scan of aorta, inferior vena cava, iliac 

29,242 1.27% 152,688 1.04% 

vasculature, or bypass grafts; complete study 

Claim involved a procedure that is not indicated for use in 

adults: 

18,826 0.82% 71,926 0.49% 

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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APPENDIX~A 

Table A-3: Allowed Charges for Part B Claims Involving Questionable Use of 

Ultrasound Procedure Codes, 2007 

Questionable Use 

High-Use Counties 

Allowed 

Charges 

Percentage of 

Allowed 

Charges 

A 

Allowed 

Charges 

ll Other Counties 

Percentage of 

Allowed 

Charges 

76700 Ultrasound, abdominal, real time with image 

documentation, complete 

76705 Ultrasound, abdominal, limited (e.g., single organ, 

Claim involved a combination of procedures billed for the same 

beneficiary, on the same day, by the same provider: 

quadrant, followup) 

76830 Ultrasound, transvaginal documentation, complete 

76856 Ultrasound, pelvic (nonobstetric), real time with image 

$107,139 0.03% $616,248 0.03% 

documentation, complete 

93925 Duplex scan of lower extremity arteries or arterial 

bypass grafts; complete bilateral study 

93978 Duplex scan of aorta, inferior vena cava, iliac 

$3,554,520 1.06% $15,638,645 0.88% 

vasculature, or bypass grafts; complete study 

Claim involved a procedure that is not indicated for use 

in adults: 

$3,190,638 0.95% $10,745,783 0.60% 

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. 

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DEPARTMEf\.lT OF HEALTH & HUMAN SE~ICF.S

200 tncMopIo_......_ sw

W8sh1ngtQn. OC 20201

DATE:

TO:

FROM:

MAY 1 1 2009

Daniel R. Levinson

Inspector Gcncral

C' .. 1.-<-3-<'J}"'~ ~nc Fn7.7.cTa

ACling Administrator

SUBJECf: Office of InspcctorGencral (DIG) Draft Report: "Medicare I)art B Billing for

Ultrasound" OEI-OI-Og-ooloo

Thank you for the opportunity to review and comment on the above-referenced DIG draft report.

Medicare Part B covers ultrasound services provided in ambulatory settings. such as doctors'

offices and tcsting centers. In 2007. Medicare spent over $2 billion for about 17 million

ultrasound services. The DIG found, among other things. a high concentr.ltion of ultrasound

providers and/or services in certain counties, which may indicate areas where Medicare's

program Sllfegul,rd eITons should be enhanced.

The OlG reported lhal in 2007. 20 high-use counties accounted for 16 percent of Part B spending

on ultrawund services despite having only 6 percent of Medicare beneficiaries. The DIG also

found 3.2 million claims with questionable chnracteristics thaI raise conecrns aboullhc

appropriatcness ofthcse claims. These claims represent $403 million in Part B charges.

Furthermore, thc 010 found thaI th~ avcrage per-beneficiary spending on ultrasound serviccs in

the 20 high-usc counties was more than threc times that for beneficiarics in the rest ofthe

country.

The DIG found that lack of a prior service elaim by thc ordering doctor was the most common

questionable charactcristic. Other characteristics. such as questionable usc of procedure codes.

wcre less common bul more prevalent in high-usc counties than other counties. In addition,

certain providers billed for a large number of ultrasound claims with questionable characteristics.

such as suspect combinations of ultrasotmd services for the same beneficiary.

The DIG made the following re<:ommendalions:

DIG RttGmmt-ndation

Monitor ultrasound claims data to detect qucstionable claims. This would reduce Medicare's

vulnerability to questionable claims for ullrasound services by enabling eMS to devclop claimsprocessing edits that nag these qucstionable claims for review prior 10 payment.

Δ APPENDIX~B 

Agency Comments 

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Page 2 - Danicl R. Levinson

eMS Rcs(lllllse

The CMS concurs. CMS will share the OIG findings on questionable ultrasound claims with the

Medicare Administrative Contraetors (MACs) for potential additional prepay edits and prepay

medical review. CMS will inform MACs ofthis issue so that they may consider it when

prioritizing their medical review strntcgies as part ofthe CMS effort to protect the Medicare I'art

D Trust Fund.

DIG Recommendation

Take action when providers bill for high numbers of questionable claims for uhrdSOund services.

When its monitoring identifies providers that bill for large numbers of questionable claims, CMS

should revicw thcir claims to ensure that they are legitimate prior to payment. IfCMS

determines that such providers submit fraudulcnt claims, it should take steps to revoke lheir

Medicare billing numbers.

Thc CMS concurs. eMS will take appropriate action to forward the listing of qucstionable

claims to the Recovery Audit Contractors (RACs) and MACs. The RACs revicw Medicare

claims on a post payment basis and are tasked with identifying inappropriate payments. While

CMS docs not mandatc areas for RAC review, we will share lhis infonnation with them. We

will instruct the MACs to consider lhis ultrasound issue when prioritizing their medical review

strntcgies.

lbe DIG has recommended that eMS take action if it determines that ultrasound providers

submit fraudulent claims. We request the DIG share with CMS the information on those

providers they believe may have been inappropriately paid. When CMS receives lhis

information, we will sharc il with our integrity contractors for appropriate action. In some cases,

the contractors may take administrativc action(s) including placing the provider on prepayment

review, collccting overpayments, and/or initiating payment suspensions. Additionally, for

reviews that result in findings of potential fraud, the contractor may develop a case for referral to

the DIG for additional action.

The CMS thanks the DIG for its efforts on this rcpon and for highlighting lhis potential

vulnerability in the Medicare program. eMS is committed to continually reviewing and refining

our processes to improve the Medicare program, and we will take the findings ofthis report

under consideration as we continue to strengthen our oversight efforts to further reduce improper

payments in the Medicare program. Wc look forward to continuing to work with the DIG tp

identify and prevent fraud, waste, and abuse in the Medicare program.

I

APPENDIX~B 

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Δ ACKNOWLEDGMENTS 

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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