Department of Health and Human Services 

OFFICE OF

INSPECTOR GENERAL

 

MEDICARE PAYMENTS FOR 

DIAGNOSTIC RADIOLOGY 

SERVICES IN EMERGENCY 

DEPARTMENTS 

 

Daniel R. Levinson 

Inspector General 

April 2011 

OEI-07-09-00450 
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EXECUTIVE SUMMARY EXECUTIVE SUMMARY

OBJECTIVES

To determine the extent to which, in 2008, Medicare allowed claims for 

interpretation and reports of diagnostic radiology services—specifically

computed tomography (CT), magnetic resonance imaging (MRI), and 

x-ray services—performed in hospital outpatient emergency 

departments that: 

1. met Medicare documentation requirements, 

2. were performed before beneficiaries left the hospital outpatient 

emergency departments, and

3. followed suggested documentation practice guidelines promoted by 

the American College of Radiology.

BACKGROUND

The Social Security Act and Centers for Medicare & Medicaid Services 

(CMS) regulations govern Medicare payments for all radiology services 

and require that services be medically necessary, have documentation to 

support the claims, and be ordered by physicians. 

We used the 2008 National Claims History File to identify 9.6 million 

Medicare claims ($215 million) for interpretation and reports of 

diagnostic radiology services for beneficiaries in hospital outpatient 

emergency departments. Our review consisted of two simple random 

samples of claims: a sample of 220 CT and MRI claims and a sample of 

220 x-ray claims. We used a document review instrument to review all 

medical record documentation requested from facilities for each sampled 

claim. We considered sampled claims erroneous if (1) documentation 

did not support that services were performed or (2) physicians’ orders 

were not present. We also reviewed all interpretation and reports to 

determine whether they were performed during beneficiaries’ diagnoses 

and treatments in hospital outpatient emergency departments. Finally, 

we reviewed interpretation and reports for all sampled claims for 

consistency with the American College of Radiology’s suggested 

documentation practice guidelines. 

FINDINGS

In 2008, Medicare claims for interpretation and reports of 19 percent 

of CTs and MRIs and 14 percent of x-rays in hospital outpatient 

emergency departments were erroneous because of insufficient 
 

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EXECUTIVE SUMMARY

documentation. Of the nearly 3 million claims allowed for 

interpretation and reports of CT and MRI services in hospital 

outpatient emergency departments in 2008, Medicare erroneously 

allowed 19 percent, amounting to nearly $29 million. Of the nearly 

6.6 million claims allowed for interpretation and reports of x-ray 

services in hospital outpatient emergency departments in 2008, 

Medicare erroneously allowed 14 percent, amounting to nearly 

$9 million. Physicians’ orders were not present in medical record 

documentation for 12 percent of CT and MRI interpretation and report 

claims, amounting to nearly $18 million. Physicians’ orders were not 

present in medical record documentation for 9 percent of x-ray 

interpretation and report claims, amounting to $5 million. 

Documentation was not provided to support that interpretation and 

reports had been performed for 12 percent of CT and MRI claims, 

amounting to nearly $19 million, and 8 percent of x-ray claims, 

amounting to $5 million. 

In 2008, Medicare paid for interpretation and reports performed for

16 percent of x-rays and 12 percent of CTs and MRIs after 

beneficiaries left hospital outpatient emergency departments; CMS 

offers inconsistent payment guidance on the timing for 

interpretation. CMS’s guidance to contractors states that contractors 

are to pay only for the interpretation performed “at the same time” as 

the diagnosis and treatment of the beneficiary in the emergency room if 

contractors receive multiple claims from, for example, the emergency 

room physician and the radiologist. However, contractors are not 

required to confirm that the interpretation was performed while the 

beneficiary was in the emergency department if only one claim is 

received. Medicare allowed more than $10 million (16 percent of claims) 

for interpretation and reports of x-rays that were performed after 

beneficiaries left hospital outpatient emergency departments and, based 

on OIG’s prior work in this area, may not have contributed to

beneficiaries’ diagnoses and treatments. Of the $10 million, $7.5 million 

was for claims that had physicians’ orders and documentation to show 

that interpretation and reports had been performed. In addition, 

Medicare allowed $19 million for interpretation and reports of CTs and 

MRIs that were performed after beneficiaries left hospital outpatient 

emergency departments. Of the $19 million, $5.4 million was for claims 

that had physicians’ orders and documentation to show that 

interpretation and reports were performed. 
 

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EXECUTIVE SUMMARY

Interpretation and reports for 71 percent of x-rays and 69 percent of 

CTs and MRIs in hospital outpatient emergency departments did not 

follow one or more suggested documentation practice guidelines 

promoted by the American College of Radiology. Seventy-one 

percent of interpretation and reports for x-rays did not follow one or 

more suggested practice guidelines. Sixty-nine percent of interpretation 

and reports for CTs and MRIs did not follow one or more suggested 

practice guidelines. Documentation standards for interpretation and 

reports are essential for determining whether diagnostic radiology 

services contribute to beneficiaries’ diagnoses and treatments. 

RECOMMENDATIONS

We recommend that CMS: 

Educate providers on the requirement to maintain documentation on 

submitted claims. 

Adopt a uniform policy for single and multiple claims for 

interpretation and reports of diagnostic radiology services to require 

that claimed services be contemporaneous or identify 

circumstances in which noncontemporaneous interpretations may 

contribute to the diagnosis and treatment of beneficiaries in hospital 

outpatient emergency departments.

Take appropriate action on the erroneously allowed claims identified 

in our sample. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In its written comments on the report, CMS concurred with the first and 

third recommendations. CMS did not concur with the second 

recommendation. 

In response to the first recommendation, CMS indicated that it will 

issue an educational article to the provider community to emphasize 

that documentation requirements will be enforced. In response to the 

third recommendation, CMS indicated that upon receipt of the files from 

the Office of Inspector General, it will take appropriate action. CMS 

will instruct the Medicare Administrative Contractors to consider this 

issue when prioritizing their medical review strategies or other 

interventions. 
 

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EXECUTIVE SUMMARY

In response to the second recommendation, CMS indicated that it does 

not believe that a single billed interpretation must, in all cases, be 

contemporaneous with the beneficiary’s diagnosis and treatment to 

contribute to that diagnosis and treatment. A uniform policy requiring 

that interpretation and reports be contemporaneous with, or, if not 

contemporaneous, demonstrably contribute to the beneficiary’s 

diagnosis and treatment could reduce unexplained complexity in what is 

already a complicated billing system for medical diagnostics. We have 

revised the language of the second recommendation to clarify what we 

are recommending.
 TABLE OF CONTENTS

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

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

FINDINGS .................................................. 9 

In 2008, Medicare claims for interpretation and reports of 

19 percent of CTs and MRIs and 14 percent of x-rays in hospital 

outpatient emergency departments were erroneous because of 

insufficient documentation ................................ 9 

In 2008, Medicare paid for interpretation and reports performed

for 16 percent of x-rays and 12 percent of CTs and MRIs after 

beneficiaries left hospital outpatient emergency departments ... 11

Interpretation and reports for 71 percent of x-rays and 69 percent 

of CTs and MRIs in hospital outpatient emergency departments 

did not follow one or more suggested documentation practice 

guidelines promoted by the American College of Radiology ..... 12

RECOMMENDATIONS ..................................... 15

Agency Comments and Office of Inspector General Response.... 16

APPENDIXES ............................................. 18

A: Document Review Instrument.......................... 18

B: Point Estimates and Confidence Intervals ................ 19

C: Agency Comments ................................... 22

ACKNOWLEDGMENTS ..................................... 24
 

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 INTRODUCTION

OBJECTIVES 

To determine the extent to which, in 2008, Medicare allowed claims for 

interpretation and reports of diagnostic radiology services—specifically 

computed tomography (CT), magnetic resonance imaging (MRI), and 

x-ray services—performed in hospital outpatient emergency 

departments that:

1. met Medicare documentation requirements, 

2. were performed before beneficiaries left the hospital outpatient 

emergency departments, and

3. followed suggested documentation practice guidelines promoted by 

the American College of Radiology.

BACKGROUND

In 2005, the Medicare Payment Advisory Commission testified before 

Congress about the increasing cost of diagnostic radiology services and 

the potential overuse of these services. In 2009, the Senate Finance 

Committee released Transforming the Health Care Delivery 

System: Proposals to Improve Patient Care and Reduce Health Care 

Costs, which indicated that the number of imaging services increased 

more than other Medicare physician services for the period under 

review. 

The Social Security Act (the Act) and Centers for Medicare & Medicaid 

Services (CMS) regulations govern Medicare payments for all services, 

including diagnostic radiology services,1 and require that these services 

be ordered by physicians, have documentation to support the claims, 

and be medically necessary. The Act states that Medicare payments 

can be made when providers furnish appropriate information about the 

service (i.e., services are ordered by practitioners with clinical privileges 

or, consistent with State law, by other practitioners authorized by the 

medical staff and the governing body to order the services. We refer to 

these practitioners as physicians in this report).2 Further, Medicare 

pays only for services considered to be reasonable and necessary.3

1 For the purposes of this report, diagnostic radiology services include x-rays, CTs, and 

MRIs.

2 Section 1833(e) of the Act; 42 CFR § 482.26(b)(4).

3 Section 1862(a)(1)(A) of the Act; 42 U.S.C. § 1395y(a)(1).
 

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INTRODUCTION

Generally, reasonable and necessary services are those used to diagnose 

or treat illness or injury or to improve the functioning of a malformed 

body part.4

Payment for Interpretation of Diagnostic Tests Furnished to Emergency 

Room Patients

 

As a condition of fee schedule payment, services are required to 

contribute directly to the diagnosis or treatment of an individual 

beneficiary.5 When Medicare Administrative Contractors (MAC) receive

a single claim for interpretation and report, “they must presume that 

the one service billed was a service to the individual beneficiary rather 

than a quality control measure ...”6

However, when a MAC receive[s] multiple claims for the same 

interpretation “[MACs must] pay for the interpretation and report that 

directly contributed to the diagnosis and treatment of the individual 

patient.”

 The Medicare Claims Processing 

Manual does not require contractors to confirm that interpretations 

were performed at the same time that the patient was in the emergency 

department or that the interpretation contributed to the diagnosis and 

treatment of the individual beneficiary when a single claim is 

submitted. 

7 The Medicare Claims Processing Manual goes on to state 

that MACs must “pay for the interpretation billed by the . . . radiologist 

if the interpretation of the procedure is performed at the same time as 

the diagnosis and treatment of the beneficiary.” Any other 

reinterpretation of the original interpretation (e.g., one that was 

performed after the beneficiary has left the emergency department) 

should be treated and reimbursed through the diagnosis-related group 

as part of the hospital’s quality assurance program.8

4 Section 1862(a)(1)(A) of the Act; 42 U.S.C. § 1395y(a)(1).

 

5 42 CFR § 415.102(a)(2).

6 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13, 

§ 100.1. Accessed at http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010.

7 Ibid.

8 A diagnosis-related group is a system developed as part of the prospective payment 

system to reimburse providers for treatment of similar diagnoses.
 

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INTRODUCTION

Medicare payments for diagnostic radiology services in hospital 

outpatient emergency departments have two components: a technical

component,9 paid by Part A; and a professional component, paid by 

Part B. This report addresses only the professional component, which 

includes payments for physicians’ interpretations of images and reports 

on the clinical findings for inclusion in beneficiaries’ 

hospital-maintained medical records.10 Payments for the professional 

component are sent to interpreting physicians (i.e., emergency room 

physicians or radiologists).11

After diagnostic radiology services are ordered by emergency 

department physicians, they can: 

 

• review diagnostic radiology images as part of evaluation and 

management (E/M) services for beneficiaries,12

• perform interpretation and reports of diagnostic radiology services, 

and/or 

 

• consult with radiologists for their interpretation and reports on the 

findings for diagnostic radiology services.13

Claims submitted for interpretations without complete written reports 

do not meet the conditions for payment. 

 

9 The technical component of diagnostic radiology services includes the administration 

and supervision of diagnostic equipment, supplies, and use of facilities. CMS Medicare 

Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13, § 20. Accessed at 

http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010. 

10 42 CFR § 415.120(a).

11 The physician should use modifier 26 to bill the professional component. American 

Medical Association, Current Procedural Terminology, 2008.

12 E/M services refer to visits and consultations furnished by physicians. CMS, Medicare 

Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 13, § 100.1. Accessed at 

http://www.cms.gov/Manuals/IOM/list.asp on August 29, 2010. Billing Medicare for a 

patient visit requires the selection of a Current Procedural Terminology (CPT) code that 

best represents the level of E/M service performed. For example, there are five CPT codes 

(99281–99285) that may be selected to bill for office or other outpatient visits for a new 

patient. American Medical Association, Current Procedural Terminology, 2008.

13 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, 

ch. 13, § 100.1. Accessed at http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010.
 

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INTRODUCTION

Both emergency department physicians and radiologists may be paid for 

their interpretation and reports for CTs, MRIs, or x-rays.14 Medicare

generally pays for only one interpretation and report for each diagnostic 

radiology service furnished to an emergency department patient.15

Comprehensive Error Rate Testing

 

CMS monitors the rates of inappropriate payments for Medicare 

fee-for-service claims through the Comprehensive Error Rate Testing 

(CERT) program. CMS established the CERT program to randomly 

sample and review different types of service claims submitted to 

Medicare. To calculate error rates, CERT staff randomly select claims 

for services each month from each contractor that processes Medicare 

claims. CERT staff then request the medical record associated with 

each sampled claim from the provider that submitted the claim. For 

2007, the CERT-listed paid claims error rates for diagnostic radiology 

services ranged from 0 to 7 percent, and provider compliance error rates 

ranged from 0 to 29 percent depending on the contractor. Error rates 

for this report are based on a methodology different from the 

methodology used by CERT. 

Previous OIG Work

The Office of Inspector General (OIG) issued a report in July 1993 

entitled Medicare’s Payment for Interpretations of Hospital Emergency 

Room X-rays (OEI-02-89-01490). The report found that in 44 percent of 

the cases, radiologists reinterpreted sampled x-rays at least 1 day after 

the emergency departments discharged the patients. These 

reinterpretations had no effect on the treatments provided to 

beneficiaries, and OIG recommended that these be treated and 

reimbursed as part of the hospitals’ quality assurance programs. 

METHODOLOGY 

Scope

We evaluated whether claims allowed in 2008 for interpretation and 

reports of diagnostic radiology services performed in hospital outpatient 

14 The physician specialty (i.e., emergency department physician or radiologist) has no 

bearing upon which claim is paid. CMS, Medicare Claims Processing Manual (Internet-only 

manual), Pub. 100-04, ch. 13, § 100.1 Accessed at http://www.cms.gov/Manuals/IOM/list.asp

on August 29, 2010. Radiologists provided interpretation and reports for 97 percent of 

x-rays and 99 percent of CTs and MRIs for beneficiaries in hospital outpatient emergency 

departments.

15 60 Fed. Reg. 63130–63133 (Dec. 8, 1995).
 

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INTRODUCTION

emergency departments met two Medicare payment 

requirements—namely, that: (1) physicians’ orders for the services be 

present and (2) interpretation and reports be documented in the medical 

record. Although contemporaneity is not a requirement, we determined 

the percentage of interpretations that were performed after 

beneficiaries left the hospital outpatient emergency department. Based 

on prior OIG work in this area, we determined that interpretations 

performed after the patient was discharged from the emergency room 

may not have contributed to beneficiaries’ diagnosis and treatment. We 

did not evaluate the proper coding or medical appropriateness of 

diagnostic radiology services associated with claimed interpretation and 

reports. Finally, we determined whether the interpretation and reports 

followed suggested documentation practice guidelines promoted by the 

American College of Radiology, although we did not question the 

appropriateness of claims for services that did not follow these practice 

guidelines.

Data Sources

Medicare outpatient claims identification. We used the 2008 National 

Claims History Standard Analytical File to identify 46 million Medicare 

outpatient claims allowed from 10.8 million hospital emergency 

department visits not resulting in inpatient stays.16, 17 From these 

46 million claims, we identified claims that (1) were for diagnostic 

radiology services;18 (2) included modifier 26, indicating the professional 

component; (3) included codes 22 or 23 for place of service, indicating 

outpatient or emergency department settings; and (4) included 

Healthcare Common Procedure Coding System (HCPCS) codes in the 

range of 70010–76140, indicating interpretation and reports of CTs, 

MRIs, and x-rays.19 This yielded a total of 9.6 million Medicare-allowed 

claims (for a total of $215 million) for interpretation and reports in 

hospital outpatient emergency departments. Of these, Medicare 

allowed 3 million claims (for a total of $151 million) for interpretation 

16 We included claims with the following Ambulatory Payment Classifications: 00609, 

00613, 00614, 00615, or 00616.

17 Allowed claims were for services performed up to 2 days after the beneficiary’s 

discharge from the hospital outpatient emergency department because nearly all claims for 

interpretation and reports were created within 2 days of discharge.

18 We included claims with the following Revenue Centers: 320, 321, 322, 323, 324, 329, 

350, 351, 359, 610, 611, 612, or 619.

19 We consulted with a practicing board-certified radiologist to identify which HCPCS 

codes to include.
 

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INTRODUCTION

and reports of CTs and MRIs and 6.6 million claims (for a total of 

$64 million) for interpretation and reports for x-rays. 

Sample selection. From the 9.6 million claims that we identified for 

interpretation and reports, we selected two simple random samples of 

claims for our review. The first sample included 220 CT and MRI 

claims, and the second sample included 220 x-ray claims. See Table 1 

for population and sample statistics. 

 Table 1: Population and Sample Claims 

Documentation request

Stratum Claims in Population Sample Size

CT and MRI claims 2,979,761* 220

X-ray claims 6,618,103 220

 Total 9,597,864 440

* Of the 2,979,761 claims, 2,906,441 were for CTs and 73,320 were for MRIs.

Source: OIG analysis of claims data, 2010.

To request medical documentation necessary to conduct this study, we

contacted—up to three times, if needed—the facilities where claimed 

services were provided. Although we established contact with all 

facilities, we had five sampled claims for which none of the 

corresponding five facilities provided the documentation we requested.

. We requested medical record documentation

from facilities that provided care to Medicare beneficiaries on the 

sampled dates of service. This request included all documentation 

(including physicians’ orders) relevant to diagnostic radiology services, 

and interpretation and reports for those services provided in hospital 

outpatient emergency departments. 

20

Analysis

 

We will forward these claims to CMS for appropriate action. Because 

we made contact with these five facilities, we determined the five claims 

from these facilities to be undocumented for the purposes of our study. 

Therefore, we consider our response rate to be 100 percent. 

We created a document review instrument (see Appendix A) to guide

our review of the medical records to ensure that all information was 

20 The OEI Medical Review Policy, June 2006, recommends treating sampled claims as 

undocumented/unsubstantiated services when contact was made with providers but OEI 

never received the corresponding medical records. 
 

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INTRODUCTION

captured and that all reviews were consistent. During development of 

the document review instrument, we conducted structured interviews 

with officials from the CMS central office and staff for all 10 MACs to 

ensure that we included relevant questions. To pretest the document 

review instrument, we conducted documentation reviews of 24 medical 

records with staff from two hospitals, including radiologists, emergency 

department physicians, and compliance officers.21

We reviewed documentation from medical records for all sampled claims 

to determine whether interpretation and reports (1) were ordered by 

physicians, (2) were present in the medical record, (3) were performed

contemporaneously with (i.e., at the same time as) diagnoses and 

treatments of beneficiaries in the hospital outpatient emergency 

departments, and (4) followed suggested documentation practice 

guidelines promoted by the American College of Radiology. To 

determine whether interpretation and reports were performed

contemporaneously with beneficiaries’ diagnoses and treatments, we 

used the dictated dates and times on the interpretation and reports and 

evaluated physicians’ notes for clinical findings and/or consultations 

with the radiologists. 

 

We considered claims erroneous if (1) physicians’ orders were not part of 

the medical record documentation or (2) documentation did not support 

that interpretation and reports were performed. Although lack of 

contemporaneity does not solely determine whether a claim is erroneous 

in instances in which a single claim is submitted, we sought to 

determine whether interpretation and reports were performed

contemporaneously with beneficiaries’ diagnoses and treatments in 

hospital outpatient emergency departments. To establish 

contemporaneity, we determined primarily whether interpretation and 

reports were dictated after beneficiaries left hospital outpatient 

emergency departments. In the absence of documented dictation times

on interpretation and reports, we looked for other documentation in the 

medical records that clearly indicated that information from the 

interpretation and reports was communicated after beneficiaries left 

hospital outpatient emergency departments. 

As an additional component of our medical record documentation 

review, we determined the extent to which interpretation and reports

contained information consistent with suggested practice guidelines and 

21 These medical records were not included in our final sample.
 

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INTRODUCTION

technical standards for documentation for interpretation and reports 

from the American College of Radiology. We used these suggested 

practice guidelines because CMS has not established minimum 

documentation standards for interpretation and reports.22

We projected our findings to the population of Medicare claims listed in 

Table 1. See Appendix B for point estimates and confidence intervals. 

 We were 

able to determine whether practice guidelines were followed for the 

194 CT and MRI claims and for the 202 x-ray claims that included 

documentation of the interpretation and reports. 

Standards

This study was conducted in accordance with the Quality Standards for 

Inspections approved by the Council of the Inspectors General on 

Integrity and Efficiency.

22 The American College of Radiology Practice Guidelines and Technical Standards are 

educational tools designed to provide consensus-based, scientifically valid, and medically 

credible information to assist health care providers in delivering effective, efficient, 

consistent, and safe medical care. Accessed at 

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx on 

October 1, 2010. Although OIG used industry-suggested documentation practice guidelines 

and technical standards in this study, it does not constitute endorsement or official Federal 

guidance. 
 

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In 2008, Medicare claims for interpretation and 

reports of 19 percent of CTs and MRIs and 

14 percent of x-rays in hospital outpatient 

emergency departments were erroneous 

because of insufficient documentation 

 FINDINGS

Of the 3 million claims allowed for 

interpretation and reports of CT 

and MRI services in 2008, 

Medicare erroneously allowed 

19 percent. Medicare allowed 

$29 million for interpretation and 

reports that did not have 

physicians’ orders as part of the medical record documentation and/or 

did not have documentation to support that interpretation and reports 

were performed (see Table 2). 

Table 2: Erroneous Claims and Amounts for CT and MRI 

Interpretation and Reports

Type of Error Claims 

(percentage) Allowed Amount 

Did not have physicians’ orders as 

part of the medical record 

documentation

11.8 $17,619,327

Did not have documentation to 

support that interpretation and 

reports were performed

11.8 $18,591,135

 Total errors (gross) 23.6 $36,210,462

(Overlapping errors) 4.5 $7,257,343*

 Total errors (net) 19.1 $28,953,119

* Relative precision exceeds 50 percent; the 95-percent confidence interval for this estimate is 

$2,602,939–$11,911,747.

Source: OIG medical review of 2008 claims.

Of the nearly 6.6 million claims allowed for interpretation and reports of 

x-ray services in 2008, Medicare erroneously allowed 14 percent. 

Medicare allowed almost $9 million for interpretation and reports that 

did not have physicians’ orders as part of the medical record 

documentation or did not have documentation to support that 

interpretation and reports were performed (see Table 3).
 

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FINDINGS

Table 3: Erroneous Claims and Amounts for X-Ray 

Interpretation and Reports 

Type of Error Claims 

(percentage) Allowed Amount 

Did not have physicians’ orders as 

part of the medical record 

documentation

8.6 $5,448,504

Did not have documentation to 

support that interpretation and 

reports were performed

8.2 $5,418,121 

 Total errors (gross) 16.8 $10,866,624

(Overlapping errors) 2.7 $1,889,468*

 Total errors (net) 14.1 $8,977,156

*Relative precision exceeds 50 percent; the 95-percent confidence interval for this estimate is 

$361,541–$3,417,396.

Source: OIG medical review of 2008 claims.

Physicians’ orders were not present in medical record documentation for 

12 percent of CT and MRI claims and 9 percent of x-ray claims

Medicare allowed almost $18 million for interpretation and report 

claims of CTs and MRIs not supported by documented physicians’ 

orders. Medicare allowed $5 million for interpretation and report 

claims of x-rays that did not have documented physicians’ orders. As a 

condition for Medicare payment for these services, medical records must 

include documented physicians’ orders. 

Documentation was not provided to support that interpretation and reports 

were performed for 12 percent of CT and MRI claims and 8 percent of x-ray 

claims

Medicare allowed almost $19 million for undocumented interpretation 

and reports of CTs and MRIs. Medicare allowed $5 million for 

undocumented interpretation and reports of x-rays. The Act states that 

as a condition for Medicare payment, providers must furnish 

appropriate information about the service (i.e., documentation to 

support that the service was performed). 
 

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FINDINGS

CMS’s guidance on

payment for 

interpretation of 

diagnostic tests 

furnished to 

emergency room patients offers inconsistent direction regarding 

whether interpretations are payable only if they were performed while 

patients were in the emergency room. 

According to CMS guidance, if claims processing contractors receive

multiple billing claims from, for example, the emergency room physician 

and the radiologist, contractors are to pay only for the interpretation 

performed “at the same time” as the diagnosis and treatment of the 

beneficiary in the emergency room. However, if only one claim is 

received, contractors are not required to confirm that the interpretation 

was performed while the beneficiary was in the emergency 

department.23

Interpretation and reports for 16 percent of x-rays were performed after 

beneficiaries left hospital outpatient emergency departments 

 

Medicare allowed more than $10 million for interpretation and reports 

of x-rays that were performed after beneficiaries left hospital outpatient 

emergency departments. These interpretations may not have 

contributed to the diagnosis and treatment of beneficiaries, given prior 

OIG work questioning the value of interpretations performed after 

patients were discharged from the emergency room. We identified more 

than $7.5 million of these claims that did not overlap with the erroneous 

payments previously described in Table 3. In one example, a 

beneficiary was discharged with the emergency department physician 

indicating a “possible fibular head fracture.” However, documentation 

indicated that the radiologist’s interpretation and report was not 

performed until the following day. In another example, the beneficiary 

was discharged from the hospital at 9:53 p.m., but the x-ray was not 

interpreted until 9:45 a.m. the following day. 

For 25 percent of x-ray claims, contemporaneity was difficult to 

establish because documentation in the medical record on dictation 

times was incomplete. In one medical record, the emergency 

department notes included an interpretation of a chest x-ray; however, 

23 CMS, Medicare Claims Processing Manual (Internet-only manual), Pub. 100-04, ch. 

13, § 100.1. Accessed at http://www.cms.gov/Manuals/IOM/list.asp on October 1, 2010.

In 2008, Medicare paid for interpretation and 

reports performed for 16 percent of x-rays and 

12 percent of CTs and MRIs after beneficiaries 

left emergency departments 
 

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FINDINGS

the record said: “[T]he radiologist will read this later. If there is any 

significance to that, we will notify the patient.” This documentation 

suggests that the treating physician was preparing to discharge the 

beneficiary prior to receiving the report from radiology. Although the 

final interpretation and report was included in the medical record and 

was dictated on the same day as the beneficiary’s emergency room visit, 

it was difficult to determine whether the radiologist verbally 

communicated the interpretation and report to the treating physician 

prior to discharge. 

Interpretation and reports for 12 percent of CTs and MRIs were performed

after beneficiaries left hospital outpatient emergency departments 

Medicare allowed more than $19 million for interpretation and reports 

of CTs and MRIs that were performed after beneficiaries left hospital 

outpatient emergency departments. Presumably, these interpretation 

and reports did not contribute to beneficiaries’ diagnoses and 

treatments. We identified $5.4 million of these claims that did not 

overlap with the erroneous payments previously described in Table 2. 

For 27 percent of CT and MRI claims, contemporaneity was difficult to 

establish because documentation in the medical record on dictation 

times was incomplete. 

Interpretation and reports for 71 percent of 

x-rays and 69 percent of CTs and MRIs in 

hospital outpatient emergency departments did 

not follow one or more suggested 

documentation practice guidelines promoted by 

the American College of Radiology 

Of the 9.6 million x-ray, CT, and 

MRI claims allowed, 

interpretation and reports did not 

follow suggested documentation 

practice guidelines for 71 percent 

of x-ray claims and 69 percent of 

CT and MRI claims. At the time 

of our review, CMS had not 

established minimum documentation standards for interpretation and 

reports of diagnostic radiology services. However, the American College 

of Radiology provides suggested practice guidelines for documentation of 

interpretation and reports as an educational tool to help practitioners 

deliver effective, efficient, consistent, and safe medical care. While the 

American College of Radiology indicates that these guidelines are not 

inflexible rules or practice requirements and are not intended to 

establish a legal standard of care, we used some of these practice 

guidelines, specifically dictation date and time, when available, to 

establish whether interpretation and reports contributed to diagnoses 

and treatments through contemporaneity. 
 

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FINDINGS

Seventy-one percent of interpretation and reports for x-rays did not follow 

one or more suggested practice guidelines for documentation

Seventy-one percent of interpretation and reports for x-rays did not 

follow one or more suggested practice guidelines (see Table 4). Although

following these practice guidelines is not required, the dictation date 

and time are essential to establish contemporaneity and to establish 

that these interpretation and reports were performed while 

beneficiaries were in hospital outpatient emergency departments. The 

time of dictation was missing from 25 percent of interpretation and 

reports, and the date of dictation was missing from 18 percent of 

interpretation and reports. In certain instances, we had to rely on other 

documentation to establish contemporaneity. For example, notes in 

medical records may have indicated that interpretation and reports 

were communicated by the radiologists to the treating emergency 

department physicians while beneficiaries were in hospital outpatient 

emergency departments. 

Table 4: American College of Radiology Practice Guidelines 

for X-Rays

Practice Guidelines 

Percentage of Interpretation and 

Reports for X-Rays That Did Not 

Follow Suggested Practice Guidelines 

(n=202)

Time examination performed 48.5

Time report dictated 24.8

Date report dictated 18.3

Referring physician 14.9

Date/time report transcribed 9.9

Date examination performed 1.0

Type of examination performed 0.5

Name of interpreting physician 0.5

Procedures and materials 0.5

Beneficiary identifier 0.0

Findings, limitations, and clinical issues 0.0

Diagnosis, if relevant 0.0

Missing at least one practice guideline 71.3

Source: OIG analysis of claims data, 2010.
 

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FINDINGS

Sixty-nine percent of interpretation and reports for CTs and MRIs did not 

follow one or more suggested practice guidelines for documentation

Sixty-nine percent of interpretation and reports for CTs and MRIs did 

not follow one or more suggested practice guidelines (see Table 5). 

Although following these practice guidelines is not required, dictation 

date and time are critical to establishing that the results of the 

interpretation and report are communicated in a timely manner to the 

treating physician in the emergency department. The time of dictation 

was missing from 27 percent of interpretation and reports, and the date 

of dictation was missing from 18 percent of interpretation and reports. 

However, as with interpretation and reports for x-rays, we relied on 

other documentation to establish contemporaneity.

Table 5: American College of Radiology Practice Guidelines 

for CTs and MRIs

Practice Guidelines 

Percentage of Interpretation and 

Reports for CTs and MRIs That Did

Not Follow Suggested Practice 

Guidelines (n=194)

Time examination performed 45.4

Time report dictated 26.8

Date report dictated 18.0

Date/time report transcribed 12.9

Referring physician 9.8

Beneficiary identifier 1.0

Date examination performed 1.0

Name of interpreting physician 1.0

Procedures and materials 1.0

Type of examination performed 0.5

Findings, limitations, and clinical issues 0.5

Diagnosis, if relevant 0.5

Missing at least one practice guideline 68.6

Source: OIG analysis of claims data, 2010.
 

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 RECOMMENDATIONS RECOMMENDATIONS

In 2008, Medicare erroneously allowed 19 percent of claims for CT and 

MRI interpretation and reports in hospital outpatient emergency 

departments, amounting to nearly $29 million for interpretation and 

reports that were not documented and/or not ordered by physicians. 

Medicare erroneously allowed 14 percent of claims for x-ray 

interpretation and reports in hospital outpatient emergency 

departments, amounting to nearly $9 million. These claims were 

erroneous because they were not documented and/or were not ordered

by physicians. CMS guidance is inconsistent regarding whether 

diagnostic radiology interpretations are payable only if they were 

performed while patients were in the emergency room. We found that 

16 percent of interpretation and reports for x-rays and 12 percent of 

interpretation and reports for CTs and MRIs were provided after 

beneficiaries left hospital outpatient emergency departments. Prior 

OIG work has questioned whether radiologists’ interpretations of x-rays 

after patients are discharged from the emergency room contributed to 

patient care. 

Therefore, we recommend that CMS: 

Educate providers on the requirement to maintain documentation on 

submitted claims 

CMS should remind providers of the requirement for documentation to 

support claims for payment. This could include reminding providers

about the need for the medical record documentation to include

(1) physicians’ orders to support diagnostic radiology services performed 

and (2) complete interpretation and reports.

Adopt a uniform policy for single and multiple claims for interpretation 

and reports of diagnostic radiology services to require that claimed 

services be contemporaneous or identify circumstances in which 

noncontemporaneous interpretations may contribute to the diagnosis and 

treatment of beneficiaries in hospital outpatient emergency departments 

CMS should adopt a clear and uniform policy that requires paid claims 

to be contemporaneous and to contribute to the diagnosis and treatment 

of beneficiaries in hospital outpatient emergency departments 

regardless of whether a single claim or multiple claims are submitted. 

A uniform policy requiring that interpretation and reports be 

contemporaneous with, or, if not contemporaneous, demonstrably 

contribute to the beneficiary’s diagnosis and treatment could reduce 

unexplained complexity in what is already a complicated billing system 

for medical diagnostics. 
 

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RECOMMENDATIONS

We understand, however, that diagnosis and treatment may be 

informed by interpretation of the radiology services after emergency 

department encounters. As such, CMS should clearly define exceptions 

for which noncontemporaneous interpretations may contribute to the

diagnosis and treatment of patients after they leave the emergency 

department. As one possibility, CMS may wish to consider requiring 

modifiers to track instances in which emergency department diagnostic 

interpretations were performed after patients were discharged from 

emergency department care. 

Take appropriate action on the erroneously allowed claims identified in our 

sample

We will forward information on the erroneously allowed claims 

identified in our sample to CMS in a separate memorandum. 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In its written comments on the report, CMS concurred with the first and 

third recommendations. CMS did not concur with the second 

recommendation.

CMS stated that it would continue to monitor and refine its oversight of

diagnostic radiology services. In addition, CMS will request a meeting 

with the American College of Radiology to review its suggested practice 

guidelines for the documentation of interpretation and reports of CTs, 

MRIs, and x-rays administered to patients in outpatient emergency 

departments.

In response to the first recommendation, CMS indicated that it will 

issue an educational article to the provider community to emphasize 

that documentation requirements will be enforced. 

In response to the third recommendation, CMS indicated that upon 

receipt of the files from OIG, it will take appropriate action, including 

forwarding the list of questionable claims to the Recovery Audit 

Contractor and MACs. CMS will instruct the MACs to consider this

issue when prioritizing their medical review strategies or other 

interventions.

In response to the second recommendation, CMS did not concur. CMS 

indicated that it does not believe that a single billed interpretation 

must, in all cases, be contemporaneous with the beneficiary’s diagnosis 

and treatment to contribute to that diagnosis and treatment. CMS 
 

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RECOMMENDATIONS

further indicated that continued diagnosis and treatment can extend 

beyond the emergency encounter to other followup settings. 

We agree that diagnosis and treatment may extend to other settings 

subsequent to the emergency department encounter. We maintain, 

however, that payment rules should uniformly require that an 

interpretation and report on an emergency department x-ray be 

contemporaneous with the beneficiary’s diagnosis and treatment. Or, if 

interpretations are not contemporaneous, they should satisfy some 

other criteria demonstrating the interpretations’ contribution to patient 

care. CMS’s current payment policy applies requirements 

inconsistently in different situations. When a MAC receives multiple 

claims for the interpretation and report of an emergency department 

x-ray, it pays only for the interpretation and report that was

contemporaneous with, and directly contributed to, the diagnosis and 

treatment of the beneficiary. Any other interpretation and report is 

treated as part of the hospital’s quality assurance program. In contrast, 

when a MAC receives only a single interpretation and report claim in 

connection with an emergency department x-ray, current policy drops 

the requirement for contemporaneity and contribution altogether. The 

MAC must presume that the one service billed was a medical service to 

the individual and not quality assurance and pays the claim if it 

otherwise meets any applicable reasonable and necessary test. This 

inconsistency is not explained, nor do we believe the underlying 

rationale is obvious. We have revised the language of the second 

recommendation to clarify what we are recommending.

The full text of CMS’s comments can be found in Appendix C.
 

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Document A: Document Review Instrument

 APPENDIX ~ A
 

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 APPENDIX ~ B

Table B: Point Estimates and Confidence Intervals

Description Sample 

Size (n)

Point 

Estimate

95-Percent

Confidence Interval

Percentage of allowed claims lacking documented physicians’ orders for interpretation 

and reports of computed tomography (CT) and magnetic resonance imaging (MRI) 220 11.8 7.5–16.1

Allowed amount of claims lacking documented physicians’ orders for interpretation and 

reports of CTs and MRIs 220 $17,619,327 $10,954,812–$24,283,841

Percentage of allowed claims for interpretation and reports for CTs and MRIs that were 

not documented 220 11.8 7.5–16.1

Allowed amount of claims for interpretation and reports for CTs and MRIs that were 

not documented 220 $18,591,135 $11,620,055–$25,562,216

Percentage of allowed claims for CTs and MRIs that were not documented or lacked 

physicians’ orders (gross) 220 23.6 16.7–30.6

Allowed amount of claims for CTs and MRIs that were not documented or lacked 

physicians’ orders (gross) 220 $36,210,462 $24,959,322–$47,461,602

Percentage of allowed claims for CTs and MRIs that were not documented or lacked 

physicians’ orders (overlapping) 220 4.5 1.8–7.3

Allowed amount of claims for CTs and MRIs that were not documented or lacked 

physicians’ orders (overlapping) 220 $7,257,343 $2,602,939–$11,911,747

Percentage of allowed claims for CTs and MRIs that were not documented or lacked 

physicians’ orders (net) 220 19.1 13.9–24.3

Allowed amount of claims for CTs and MRIs with no documented physicians’ orders or 

having undocumented interpretation and reports (net) 220 $28,953,119 $20,756,618–$37,149,619

Percentage of allowed claims with no documented physicians’ orders for interpretation 

and reports of x-rays 220 8.6 4.9–12.4

Allowed amount of claims with no documented physicians’ orders for interpretation and 

reports of x-rays 220 $5,448,504 $3,054,537–$7,842,471

Percentage of allowed claims for interpretation and reports for x-rays that were not 

documented 220 8.2 4.5–11.8

Allowed amount of claims for interpretation and reports for x-rays that were 

not documented 220 $5,418,121 $2,952,704–$7,883,537

Percentage of allowed claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (gross) 220 16.8 10.9–22.7

Allowed amount of claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (gross) 220 $10,866,624 $6,922,264–$14,810,985

Percentage of allowed claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (overlapping) 220 2.7 0.6–4.9

Allowed amount of claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (overlapping) 220 $1,889,468 $361,541–$3,417,396

Percentage of allowed claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (net) 220 14.1 9.5–18.7

continued on next page
 

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APPENDIX ~ B

Table B: Point Estimates and Confidence Intervals, Continued

Description Sample 

Size (n)

Point 

Estimate

95-Percent

Confidence Interval

Allowed amount of claims for interpretation and reports for x-rays that were not 

documented or lacked physicians’ orders (net) 220 $8,977,156 $5,972,273–$11,982,039

Percentage of allowed claims for interpretation and reports for x-rays that were not 

contemporaneous with beneficiaries’ diagnoses and treatments in hospital outpatient 

emergency departments

220 15.9 11.0–20.8

Allowed amount of claims for interpretation and reports for x-rays that were not 

contemporaneous with beneficiaries’ diagnoses and treatments in hospital outpatient 

emergency departments

220 $10,170,821 $6,977,447–$13,364,195

Allowed amount of claims for x-rays that were not contemporaneous and did not overlap 

with those claims with no documented physicians’ orders or having undocumented 

interpretation and reports 220 $7,575,923 $4,754,169–$10,397,677

Percentage of allowed claims for interpretation and reports for CTs and MRIs that were 

not contemporaneous with beneficiaries’ diagnoses and treatments in hospital 

outpatient emergency departments

220 11.8 7.5–16.1

Allowed amount of claims for interpretation and reports for CTs and MRIs that were not 

contemporaneous with beneficiaries’ diagnoses and treatments in hospital outpatient 

emergency departments

220 $19,334,315 $11,892,195–$26,776,434

Allowed amount of claims for CTs and MRIs that were not contemporaneous and did not 

overlap with those claims with no documented physicians’ orders or having 

undocumented interpretation and reports 220 $5,360,725 $838,027–$9,883,424

Percentage of allowed claims for interpretation and reports for x-rays not following at 

least one suggested practice guideline promoted by the American College of Radiology 202 71.3 65.0–77.6

X-ray interpretation and reports did not follow practice guideline for listing time 

examination was performed 202 48.5 41.6–55.5

X-ray interpretation and reports did not follow practice guideline for listing time 

report was dictated 202 24.8 18.8–30.8

X-ray interpretation and reports did not follow practice guideline for listing date 

report was dictated 202 18.3 12.9–23.7

X-ray interpretation and reports did not follow practice guideline for listing referring 

physician 202 14.9 9.9–19.8

X-ray interpretation and reports did not follow practice guideline for listing date/time 

report was transcribed 202 9.9 5.7–14.1

X-ray interpretation and reports did not follow practice guideline for listing date 

examination was performed 202 1.0 0.2–3.9*

X-ray interpretation and reports did not follow practice guideline for listing type of 

examination performed 202 0.5 0.1–3.5**

X-ray interpretation and reports did not follow practice guideline for listing name of 

interpreting physician 202 0.5 0.1–3.5**

X-ray interpretation and reports did not follow practice guideline for listing procedures 

and materials 202 0.5 0.1–3.5**

continued on next page
 

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APPENDIX ~ B

Table B: Point Estimates and Confidence Intervals, Continued

Description Sample 

Size (n)

Point 

Estimate

95-Percent

Confidence Interval

X-ray interpretation and reports did not follow practice guideline for listing beneficiary 

identifier 202 0.0 0.0–1.8*

X-ray interpretation and reports did not follow practice guideline for listing findings, 

limitations, and clinical issues 202 0.0 0.0–1.8*

X-ray interpretation and reports did not follow practice guideline for listing diagnosis, if 

relevant 202 0.0 0.0–1.8*

Percentage of allowed claims for interpretation and reports for CTs and MRIs that did not 

follow at least one suggested practice guideline promoted by the American College of 

Radiology

194 68.6 62.0–75.1

CT and MRI interpretation and reports did not follow practice guideline for listing time 

examination was performed 194 45.4 38.3–52.4

CT and MRI interpretation and reports did not follow practice guideline for listing time 

report was dictated 194 26.8 20.5–33.1

CT and MRI interpretation and reports did not follow practice guideline for listing date 

report was dictated 194 18.0 12.6–23.5

CT and MRI interpretation and reports did not follow practice guideline for listing date/time 

report was transcribed 194 12.9 8.1–17.6

CT and MRI interpretation and reports did not follow practice guideline for listing 

referring physician 194 9.8 5.6–14.0

CT and MRI interpretation and reports did not follow practice guideline for listing 

beneficiary identifier 194 1.0 0.3–4.1**

CT and MRI interpretation and reports did not follow practice guideline for listing date 

examination was performed 194 1.0 0.3–4.1**

CT and MRI interpretation and reports did not follow practice guideline for listing name 

of interpreting physician 194 1.0 0.3–4.1**

CT and MRI interpretation and reports did not follow practice guideline for listing 

procedures and materials 194 1.0 0.3–4.1**

CT and MRI interpretation and reports did not follow practice guideline for listing type of 

examination performed 194 0.5 0.1–3.6**

CT and MRI interpretation and reports did not follow practice guideline for listing findings, 

limitations, and clinical issues 194 0.5 0.1–3.6**

CT and MRI interpretation and reports did not follow practice guideline for listing 

diagnosis, if relevant 194 0.5 0.1–3.6**

*Confidence intervals were calculated with an exact method based on the binomial distribution because the standard method and logit transformation method cannot be

used when no sample units possess the characteristic measured.

**Confidence intervals were calculated using the logit transformation because of poor coverage properties of the standard approximation method when a small number of 

sample units possess the characteristic of interest.

Source: Office of Inspector General analysis of claims data, 2010.
A P PEN D x c 

Agency Comments 

Centers for Medicare & Medicaid Services 

Administrator 

DEC Washington, DC 20201 2 22010 

TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Donald M. Berwick, M.D. 

Administrator 

SUBJECT: 	 Office oflnspector General (OIG) Draft Report: "Medicare Payments for 

Diagnostic Radiology Services in Emergency Departments" (OEI-07-09-00450) 

Thank you for the opportunity to review and comment on the Office ofInspector General's 

(OIG) draft report, "Medicare Payments for Diagnostic Radiology Services in Emergency 

Departments." The Centers for Medicare & Medicaid Services (CMS) appreciates the time and 

resources OIGhas invested to determine the extent to which Medicare improperly paid claims 

for diagnostic radiology services. 

According to Medicare policy, emergency department physicians and radiologists may be paid 

for their interpretation and reports for computed tomography (CT), magnetic resonance imaging 

(MRI) and x-rays, Based on its review oftwo samples (220 claims each) of9.6 million 2008 

diagnostic radiology claims, OIG concluded that: 1) Medicare claims for interpretation and 

reports of an estimated 19 percent ofCTs and MRls and an estimated 14 percent of x-rays in 

hospital outpatient emergency departments were improperly paid due to insufficient 

documentation; 2) Medicare paid for interpretation and reports made on an estimated 16 percent 

ofx-rays and an estimated 12 percent ofCTs and MRIs after beneficiaries left the hospital 

outpatient emergency departments; and 3) interpretations and reports for an estimated 71 percent 

of x-rays and an estimated 69 percent ofCTs and MRIs in hospital outpatient emergency 

departments did not follow one or more suggested documentation practice guidelines promoted 

by the American College of Radiology. 

The CMS will continue to monitor and refine our oversight of diagnostic radiology services. 

OIG made the following recommendations. 

OIG Recommendation 1 

Educate providers on the requirement to maintain documentation on the submitted claims. 

CMS Response 

The CMS concurs. CMS will issue an educational article to the provider community to 


emphasize that documentation requirements wilJ be enforced. 


OEI·07·09·00450 MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS 22 
 

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APPENDIX ~ C
 

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 ACKNOWLEDGMENTS

This report was prepared under the direction of Brian T. Pattison, 

Regional Inspector General for Evaluation and Inspections in the 

Kansas City regional office, and Deborah Walden, Deputy Regional 

Inspector General. 

Brian T. Whitley served as the team leader for this study. Other 

principal Office of Evaluation and Inspections staff from the Kansas 

City regional office who contributed to the report include Dennis Tharp

and Amber Meurs; central office staff who contributed include Kevin 

Manley, Kevin Farber, Julie Taitsman, and Jeff Weinstein. 
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 practice guidelines:

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.