Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

FRAGMENTED PHYSICIAN CLAIMS 

SEPTEMBER 1992 
OFFICE OF INSPECTOR GENERAL 

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 three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program, and management problems, and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’s Office of Audit Services (OAS) provides all 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 

assessmentsof HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’s Office of Investigations (01) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions, 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’s Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

This report was prepared by the Health Care Branch, Office of Evaluation and Inspections. 

The following persons participated in the project: 

Cathaleen A. Ahern 

David C. Hsia, M.D., J.D., M.P.H. 

Brian P. Ritchie 

To obtain a copy of this report, call the Health Care Branch at (410) 966-3148. 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

FRAGMENTED PHYSICIAN CLAIMS 
EXECUTIVE SUMMARY 

PURPOSE 

The Office of Inspector General (OIG) conducted this study to examine patterns of 

physician billing in certain cases in which a Medicare beneficiary underwent more than 

one surgical procedure on the same day. 

BACKGROUND 

This study illustrates the types of claims discussed in a September 1991 OIG report, 

“Manipulation of Procedure Codes by Physicians to Maximize Medicare and Medicaid 

Reimbursement.” Another Office of Inspector General inspection, of liver biopsies, 

identified a high rate of fragmented claims - those in which a physician billed for 

opening the abdomen and removing the gallbladder as well as biopsying the liver, for 

example. In this example, only the gallbladder removal should be billed for; the 

biopsy should not be since it was not a “separate procedure” as defined in the 

guidelines of Phvsicians’ Current Procedural Terminologv (CPT-4) and the laparotomy 

(incision) should not be as it was only an approach to the gallbladder. 

Because 63 percent of all surgical cases in that sample were fragmented, the OIG 

examined billing and payment data for other, similar surgeries, using 1988 claims. 

METHODS 

From a list of codes for exploratory surgery and biopsies, 6 codes with potential for 

incorrect billing were selected for further review. The 6 codes for biopsy and/or 

exploration were claimed 240,800 times for $54,660,400 (projected); another surgical 

code was billed on the same day 160,300 times, for $79,653,600 (projected). These 

codes were further examined. An OIG physician determined which surgical 

procedures could reasonably be performed and properly billed on the same day. The 

remaining combinations of procedures are discussed in this report. 

FINDINGS 

Physicians frequently billed for biopsies and/or explorations which were part of 

another surgical procedure, realizing as a result more than $12 million in 

overpayments in 1988: 

. Projected overpayments associated with two exploratory surgery codes, and with 

surgical biopsies of the liver and pancreas, total $7,620,565 for 1988. 

. Projected overpayments for “separate procedures” claimed inappropriately 

totalled $3,404,100. 

i 
. Projected overpayments for secondary procedures that should have been denied 

as duplicative or mutually exclusive totalled $1,721,600. 

RECOMMENDATION 

The Health Care Financing Administration should require carriers to deny or adjust 

payment for: 

(1) “exploratory” surgery performed incidently to a procedure separately billed, 

(2) biopsies performed in the course of more major surgery in the same body 

cavity, 

(3) “separate procedures” billed with another procedure, 

(9 mutually-exclusive procedures, and 

(5) claims by assistants for procedures denied when billed by surgeons. 

Proper denial of such claims can be accomplished by creating screens which reject 

exploration codes billed with any related code, adjust biopsy codes when billed with 

more major surgery, reject codes for “separate procedures” unless they are the only 

procedure claimed, reject duplicative and mutually-exclusive procedures, and pay 

assistants only when the surgeon may be paid for a procedure. 

In HCFA’s response to the draft report, they concurred in part with these 

recommendations and identified additional steps they have taken which address some 

of these concerns. We removed from the overpayment calculation two sets of codes 

dealing with breast biopsies and bone marrow biopsies. While we continue to believe 

these represent fragmented billing, HCFA believes they represent permissible coding. 

We have retained the recommendation dealing with payments to assistants at surgery, 

and will more fully develop this issue in a future inspection. The HCFA’s comments 

are included in their entirety as appendix E. 

ii 
TABLE OF CONTENTS 

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

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

PURPOSE ................................................... 1 

BACKGROUND .............................................. 1 

METHODS .................................................. 2 

FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

APPENDIX A: Laparotomies 

APPENDIX B: Breast and Bone Marrow Biopsies 

APPENDIX C: Liver and Pancreas Biopsies 

APPENDIX D: “Separate Procedures” 

APPENDIX E: HCFA’s Comments 
INTRODUCTION 

PURPOSE 

The Office of Inspector General (OIG) conducted this study to examine patterns of 

physician billing in certain cases in which a Medicare beneficiary underwent more than 

one surgical procedure on the same day. 

BACKGROUND 

Other OIG Studies This study illustrates the types of claims discussed in the 

September 1991 OIG report, “Manipulation of Procedure Codes by Physicians to 

Maximize Medicare and Medicaid Reimbursement.” 

In another inspection, on liver biopsies, the OIG selected a random 1 percent sample 

of claims for Medicare patients who underwent liver biopsies (procedure codes 47000 

and 47100). This process identified 329 claims, representing 273 patients and 290 

biopsies. In all but 17 cases, the OIG was able to identify the hospital in which the 

biopsy took place. The OIG requested the entire medical record from each of the 

hospitals. The final sample consisted of 289 claims for 237 patients representing 253 

procedures. 

Thirteen percent (39 of 289 claims) were miscoded, claiming a wedge was performed 

when actually a needle sample was taken, or vice versa, or billing when no biopsy, or 

no procedure at all, was performed. Surgeons billed for both a biopsy and an 

exploratory laparotomy in 14 claims. In 82 of 128 claims, surgeons billed for a liver 

biopsy as well as a more major procedure such as a gallbladder removal. Our findings 

from this study are reported in the December 1991 OIG report, “Liver Biopsies.” 

These findings led us to further examine the payment for exploratory surgery and 

biopsies when performed with another surgical procedure. 

Coding Concems The most important coding issue discussed in this report is what is 

called “fragmentation.” Even the simplest surgical procedure involves many steps, 

from the preparation of the skin to the incision to the control of bleeding and eventual 

suture of the incision. All of these steps are integral to the procedure itself; other, less 

obvious, links exist between the major procedure being performed and other minor 

procedures which, when performed alone, can be coded separately. Examples of the 

latter procedures are discussed in this report. 

The guidelines given to surgeons in Phvsicians’ Current Procedural Terminolorrv (CPT4), issued by the American Medical Association, discuss when a procedure may be 

considered a “separate procedure” for reporting and billing purposes. 

1 
SEPARATE PROCEDURE: Some of the listed procedures are commonly 

carried out as an integral part of a total service, and as such do not warrant a 

separate identification. When, however, such a procedure is performed 

independently of, and is not immediately related to, other services, it may be 

listed as a “separate procedure.” Thus, when a procedure that is ordinarily a 

component of a larger procedure is performed alone for a specific purpose, it 

may be considered to be a separate procedure. (Phvsicians’ Current Procedural 

Terminologv. copvright 1988.1990.) 

A gastrostomy, for example, is the creation of an artificial opening in the stomach. It 

is usually done as a component of surgery in which a cancerous or ulcerated part of 

the stomach is removed. However, when performed independently of, and not 

immediately related to, other services, it may be listed as a separate service. This 

would occur, for example, when a malnourished patient had to have a tube for feeding 

placed directly into the stomach, through the skin. 

If a carrier were to pay separately for an exploratory laparotomy (incision), a liver 

biopsy, and a cholecystectomy (removal of the gallbladder), as did occur in the sample 

of claims reviewed for the liver biopsy study, the surgeon would in effect be paid three 

times for opening the abdomen. 

METHODS 

The source of the data examined in this study is the 1988 BMAD file of procedures, a 

1 percent sample of all procedures for which Medicare was billed. From a list of 

HCPCS codes for exploratory surgery and biopsies, 6 codes with potential for incorrect 

billing were selected for further review. The 6 codes selected were billed 199,500 

times in 1988; total allowed amounts for these procedures exceeded $54 million 

(projected). Anoth er surgical code was billed on the same day for the same patient 

160,300 times, for more than $79 million (projected). 

These claims include those in which an anesthesiologist billed a different code than the 

surgeon did, creating the appearance of multiple surgeries. These claims were 

eliminated. An OIG physician determined which surgical procedures could reasonably 

be performed and properly billed on the same day. These were also eliminated, along 

with instances in which too little information was provided to make an assessment. 

Thus the overall sample was reduced from 3,598 line items to 1,599, largely due to 

eliminating those cases in which the anesthesia bill gave the appearance of multiple 

procedures having been performed. 

Limitations of the Data Since this inspection examined only billing data, errors in 

those data could distort the results. For example, claims by anesthesiologists were 

eliminated from the sample. If the codes for type of service or specialist were in 

error, some anesthesia claims may be intermingled with the claims for surgeons and 

their assistants. (Some anesthesia claims which were eliminated were shown as a “2” 

(surgery) for type of service, but as an “05” (anesthesia) for specialist type.) We did 

2 
not examine beneficiary histories to attempt to reconstruct a billing history, nor did we 

examine medical records. 

The numbers of claims referred to in the sample have been projected to their 

numbers in the universe of 1988 claims. Numbers under 2,000 (i.e., 20 sample claims) 

have a wide margin of error. They are shown, however, since they may be easily 

identified by carriers’ screening processes. 

3 
FINDINGS 

Physicians frequently billed for biopsies and/or explorations which were 

part of another surgical procedure, realizing as a result more than $12 

million in overpayments in 1988. 

Projected overpayments associated with two exploratory surgery codes, and with 

surgical biopsies of the liver and pancreas total $7,620,565 for 1988. 

The overpayments identified in this report are shown in detail in Appendices A 

through D. The spreadsheets are labeled with the code which triggered the review. 

The principal procedure for which this review determined payment could be allowed is 

identified in the left hand columns. When only “separate procedures” were billed, the 

procedure with the highest allowed amount was identified as principal and all others 

denied. The discussion below documents our findings and concerns, as well as 

identifying corrective measures taken by HCFA to address some of these issues. 

FraPmenting laparotomy claims: 

“Laparotomy” is the term used for surgical incision of the abdomen; not to be 

confused with “laparoscopy,” in which an instrument is inserted through a small slit 

into the abdomen. Some abdominal surgery, e.g., appendectomies, can be performed 

through small incisions. A laparotomy, however, is necessarily the first step in major 

surgery of the abdomen; an exploratorv laparotomy is undertaken when the surgeon 

does not know what, if any, definitive surgery will be needed. Occasionally no further 

surgery will be performed, e.g., when cancer is so widespread that removing an organ 

would not help the patient. In such cases, the surgeon correctly bills Medicare for 

having performed an exploratory laparotomy. 

When more major surgery is performed, however, the laparotomy is only the initial 

stage of that surgery. For example, if the surgeon discovers a cancerous condition 

which necessitates removing part of the colon, he or she would bill for the colectomy 

(removal of all or part of the colon), but not for the laparotomy, nor for biopsies or 

an incidental appendectomy. If, during the same surgery, the surgeon also created a 

colostomy (an opening from the colon to the surface of the body), he or she could bill 

for that, using the code which incorporates both the colectomy and colostomy. The 

same principle would apply to a third or fourth distinct procedure. It is perfectly 

appropriate to file claims for as many procedures as were performed, but not to 

fragment any one procedure into its component parts. 

Particularly egregious use of the exploratory laparotomy code is in combination with 

those codes, such as 43605 (biopsy of stomach by laparotomy) and 49220 (staging 

celiotomy [laparotomy] for Hodgkins’ disease or lymphoma [includes splenectomy, 

needle or open biopsies of both liver lobes, possibly also removal of abdominal node 

and/or bone marrow biopsies, ovarian repositioning]), in which the laparotomy is 

4 
inherent in the verbal description of the code. This may, however, represent an effort 

by the physician’s billing staff to find codes describing what the procedure was, fully 

expecting the carrier to pay only the “correct” code. 

Intra-operative breast biopsies: 

The claims associated with incisional breast biopsies were for the removal of cysts or 

for mastectomies (removal of the breast). Draft Medicare Carriers Manual 

instructions provide for “rebundling” biopsies into payments for cyst excisions and for 

mastectomies, but do not require denial of multiple claims for excisions. While the 

methodology for claims review in this study allowed two mastectomy codes (as 

presumably involving both breasts), the manual instructions deny secondary 

mastectomy codes when the principal procedure is a mastectomy. Correct use of “left” 

and “right” modifiers should allow for more precise assessment. 

The HCFA’s response to the draft version of this report indicate that they believe 

biopsies billed with excisions and mastectomies are permissible (presumably referring 

to the “one-stage” approach to diagnosing and excising cancerous tumors). We have 

retained Appendix B detailing these procedures, but have deleted the amounts paid 

from the overpayment calculation. 

Claims from two surgeons, neither an assistant: 

A chance finding was 20 cases in which a second surgeon billed for the laparotomy, 

without indicating “assistant” status, and was paid as though s/he were the primary 

surgeon. The CPT instructions provide for two surgeons or for a surgical team in 

certain instances. One surgeon’s billing for the laparotomy while another bills for a 

gallbladder extraction does not meet the criteria discussed in CPT. 

For example, two surgeons billed for operating on the same patient on the same day. 

One was allowed $1342 for a hemigastrectomy (removal of half of the stomach); the 

other, although not identified as an assistant, $517. The first surgeon was allowed 

$245 for a liver biopsy; the second $219, plus $235 for an omentectomy (removal of 

abdominal tissue). Both the biopsies and the omentectomy are “separate procedures,” 

not allowable when billed with more major procedures. The second payment for the 

hemigastrectomy is 42 percent of the first; the second liver biopsy payment is 89 

percent of the first. 

The Carriers Manual section referred to above would require denial of 

omentectomies, laparotomies, and various other incidental procedures when 

hemigastrectomy is the principal procedure. Several other major abdominal 

procedures (e.g., colectomy and cholecystectomy) have similar, although less extensive, 

lists of codes to be rebundled. This still allows for many of the overpayments 

identified in this report, both for major procedures for which rebundling is not 

required, and for those separate and incidental procedures not listed. 

5 
Claims from assistants at surgery: 

In 13 cases in which a primary as well as an assistant surgeon billed for a laparotomy, 

the average amount allowed the assistant was $53, ranging from 11 to 33 percent of 

the respective surgeon’s allowed amount. In the 23 cases in which an assistant billed 

for a laparotomy but a primary surgeon did not, the average amount allowed the 

assistant was $148. We did not attempt to determine how the carriers assigned 

allowed amounts to the solo bills of the assistants, but may study this issue separately. 

Medicare Carriers Manual instructions issued in October 1991 list procedures for 

which assistants may not bill. The only impact these instructions would have had on 

the claims reviewed in this study would have been denial of $29.41 for an assistant at 

an incisional breast biopsy. 

Facility codes differing from surgeon’s codes: 

Twelve of the exempted claims were for facility fees as well as anesthesia and 

surgeon’s fees for breast biopsies. In each case, the facility coded the biopsy code, 

although the surgeon indicated that the procedure was a cyst excision, or, in one 

instance, a mastectomy. The ambulatory surgical center (ASC) payment group for a 

biopsy is the same as the group which includes cyst excision, but lower than the 

payment the ASC could have received for a mastectomy. 

Projected overpayments for “separate procedures” billed inappropriately totalled 

$3404,100. 

An examination of the codes billed on the same day for the same patient reveals 

numerous instances of combinations that are contrary to the guidelines expressed in 

CPT-4. For example, billing for code 44005, enterolysis (cutting internal adhesions) 

for bowel obstruction (separate procedure), at the same time as any other surgery 

violates CPT guidelines. Enterolysis is typically undertaken either because the 

adhesions are causing an acute bowel obstruction or incidental to another reason for 

having opened the abdomen, such as during gallbladder surgery. In either case, a 

laparotomy is merely an approach to the surgical field, and should not be paid for 

separately. Additionally, this code for lysis of adhesions is limited to use in those cases 

in which the lesions cause a bowel obstruction. Thus code 44005 should not be billed 

when the adhesions are removed incidentally. 

See Appendix D for a list of “separate procedures,” which should be denied when 

performed with any other procedure. 

Projected overpayments for secondary procedures that should have been denied as 

duplicative or mutually exclusive totalled $1,721,600. 

Since the codes for exploratory surgery include any biopsies that were performed, any 

claim for a biopsy of an abdominal organ on the same patient on the same day 

6 
represents duplicate billing. In these cases, either the biopsy claim or the exploration 

claim should be denied. 

The primary reason for erroneous claims associated with bone marrow needle biopsies 

is billing for the actual aspiration of the material to be examined by more than one 

physician, or by one physician twice. In 86 instances, both codes 85095, bone marrow 

smear and/or cell block, aspiration only, and 85102, needle biopsy of the bone marrow, 

were billed simultaneously. Even if one was billed by a surgeon and the other by a 

pathologist, they clearly are both billing for performing the same action. The HCFA 

disagrees with this conclusion; we have retained Appendix B, but removed the 

payment amounts from the overpayment calculation. 

As mentioned earlier, several of the claims associated with breast biopsies were for 

both a partial and a radical mastectomy. We assumed that this indicated surgery on 

both breasts, so both were allowed. 

Multiple procedures within one code: 

Thirteen claims (26 line items) were for duplicate codes 19120, excision of cyst, 

fibroadenoma, etc., ... , one or more lesions. We believe this description means that 

on any one occasion, this code should be used for all the cysts, etc., removed. In these 

cases, however, both were allowed. The codes were paid at the same rate once, one 

at half of the other eight times, and one at a reduced rate four times. They are shown 

as “deny secondary procedure” in Appendix B. 

Mutually-exclusive procedures: 

Cholecystectomies are the procedures most often fragmented in all the claims 

examined as part of this report. Several were reported in conjunction with 

cholecystenterostomies, a logical impossibility, since the cholecystectomy code means 

the gallbladder was removed, and the cholecystenterostomy code that the gallbladder 

was connected to the intestine. This concern is not addressed by the draft instructions. 

7 
RECOMMENDATION 

The Health Care Financing Administration should require carriers to deny or adjust 

payment for: 

(1) “exploratory” surgery performed incidently to procedure separately billed, 

(2) biopsies performed in the course of more major surgery in the same body 

cavity, 

(3) “separate procedures” billed with another procedure, 

(4) mutually-exclusive procedures, and 

(5) claims by assistants for procedures denied when billed by surgeons. 

Proper payment of such claims can be accomplished by creating screens which reject 

exploration claims billed with any related code, adjust biopsy claims when billed with 

more major surgery in the same body cavity, reject claims for “separate procedures” 

unless they are the only procedure billed, reject claims for duplicative and mutuallyexclusive procedures, and pay assistants only when the surgeon may be paid for a 

procedure. 

This can best be done by creating software which examines claims according to a 

logical clinical sequence, rejecting for development (or outright denial) those claims 

which fail to pass the screens. The simplest version of this software would merely 

reject laparotomies and “separate procedures” done in conjunction with any other 

procedure, without further analysis. 

The HCFA has created series of combinations, which address some of the problems 

identified in this report. For example, laparotomies, lysis of adhesions, and 

omentectomies are denied in conjunction with certain abdominal procedures, but not 

with many others. 

The HCFA concurred with our recommendations concerning exploratory surgery and 

payment for separate and mutually-exclusive procedures. They disagree that biopsies 

should not be paid for when performed in the course of more major surgery, but have 

rather identified a lesser payment amount which does not pay the surgeon again for 

having opened the abdomen. In their technical comments they disagreed that 

demonstrated unbundling of breast biopsies and bone marrow biopsies. We have 

retained the appendices detailing these situations, but have removed the payments for 

them from our overpayment calculation. We will expand upon our examination of 

assistants at surgery in a future study. 

8 
APPENDIX A 

Overpayrnem ass&ted with code 49oo0, Eapbratory Lqamtomies, and with 49010, 

Retroperitoneal Laparotomies 

A -1 
49000 EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY OBS DENY ALLOW ALLOW DENY DENY DENY 

WITH OR WITHOUT BIOPSY(S), LAP, PRINCIPAL SECONDARY “SEPARATE LAP, SECONDARY 

SEPARATE PROCEDURE SURGEON PROCEDURE PROCEDURE PROCEDURE” ASSISTANT PROCEDURE 

34151 RENAL EMBOLECTOMY (ABDOMINAL INCISION) 1 $1,925.30 $320.90 

38100 SPLENECTOMY (SEPARATE PROCEDURE); TOTAL 2 $695.20 $1,429.85 $352.20 

38564 LIMITED LYMPHADENECTOMY, FOR STAGING (SEP PROC) 1 $366.50 $411.50 $100.00 

II38770 I PELVIC LYMPHADENECTOMY (SEP PROC); UNILATERAL I 1 I $672.00 1 $212.50 1 I I I II 

II43500 I GASTROSTOMY, WITH EXPLORATION I 1 I $1,069.60 $611.80 1 I $534.80 1 I $611.80 11 

II43605 I BIOPSY OF STOMACH BY LAPAROTOMY I 1 I $336.00 I $1344.00 I $1,123.10 I II 

43630 HEMIGASTRECTOMY OR DISTAL GASTRECTOMY, WITHOUT 2 $2,704.30 $235.00 $345.45 

VAGOTOMY 

43635 HEMIGASTRECTOMY OR DISTAL GASTRECTOMY, WITH 1 $291.00 $1,187.00 

VAGOTOMY 

43640 VAGOTOMY INCLUDING PYLOROPLASY, WITH OR WITHOUT 3 $3,067.45 $147.68 $865.49 $471.44 

GASTRECTOMY I 

43820 GASTROJEJUNOSTOMY 1 $800.00 $437.50 $798.50 

43830 GASTROSTOMY, TEMP (TUBE,RUBBER,PLASTIC)(SEP PROC) 2 $1,254.10 $1,231.55 $152.10 

43840 GASTRORRHAPHY, SUTURE OF PERFORATED ULCER, 3 $1,833.20 $606.90 $53.50 

WOUND OR INJURY 

II44005 I ENTEROLYSIS FOR BOWEL OBSTRUCTION (SEP PROC) I 11 I $2,233.45 1 $8,606.55 1 I $1,511.50 1 $3%.64 1 II 

DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR 1 $1,088.20 $879.55 

FOREIGN BODY REMOVAL I I I II 

II44021 I ENTEROTOMY, SMALL BOWEL; FOR DECOMPRESSION I 1 I %280.90 I $767.00 1 I I $56.20 1 II

II44050 I REDUCTION OF VOLWLUS, INTUSSUSCEPTION, BY LAP I 1 I I $1,069.60 I I $192.60 1 II 

II44110 I BIOPSY OF INTESTINE BY CAPSULE, TUBE, PERORAL I 2 I $336.00 I $1,405.80 $432.00 1 $896.00 1 I II 

44120 ENTERECTOMY, RESECTION OF SML INTESTINE; WITH 7 $1,603.30 $7,475.40 $365.60 $1,425.20 $3,014.65 

ANASTOMOSIS I I I 

44130 ENTEROENTEROSTOMY. ANASTOMOSIS fSEP PROC) I 1 I I $1.180.00 I $584.70 I 

44141 COLECTOMY, PARTIAL; WITH SKIN LEVEL CECOSTOMY OR 2 $175.00 $2,684.00 

COLOSTOMY 

44143 COLECTOMY, PARTIAL; WITH END COLOSTOMY, CLOSURE 8 $478.60 $8665.25 $738.05 $1,530.50 

DISTAL SEGMENT 

A-2 

E 
11 44145 1 COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY I 1 I I $1,571.90 I I $311.30 I I 

44160 COLECTOMY WITH REMOVAL OF TERMINAL ILEUM AND 1 $1,550.00 $820.90 II IILEOCOLOSTOMY I I I I I 

II I I 

II44320 I COLOSTOMY OR SKIN LEVEL CECOSTOMY; (SEP PROC) I 5 I $1389.16 $2.89490 I I $423.01 I 

II44345 I REVISION OF COLOSTOMY, COMPLICATED I 1 I I $567.70 I I $149.70 $131.60 

II44600 I SUTURE OF INTESTINE, LARGE OR SMALL, SINGLE I 1 I $585.60 1 $213.42 I I I 

II44605 I SUTURE OF INTESTINE; WITH COLOSTOMY I 1 I $291.00 $645.40 I I I 

44625 CLOSE ENTROSTOMY WITH RESECTION & ANASTOMOSIS 2 $641.70 $2,153.90 $1,140.70 $429.40 

44799 UNLISTED PROCEDURE, INTESTINE 2 $442.90 $3,147.15 $110.70 $450.85 

44900 I & D OF APPENDICEAL ABCESS, TRANSABDOMINAL 1 $734.20 $213.90 

44950 APPENDECTOMY 2 $671.80 $1,054.50 S895.70 $140.00 

44955 APPENDECTOMY; WHEN DONE WITH MAJOR PROCEDURE 1 $554.50 $97.50 $110.90 

47000 BIOPSY OF LIVER, PERCUTANEOUS NEEDLE 3 $1,776.90 $198.50 $58.20 

47120 HEPATECTOMY, RESECT LIVER, PARTIAL LOBECTOMY 1 $1,361.90 $156.80 

47420 CHOLEDOCHOTOMY WITH EXPLORATION, DRAINAGE OR 2 $300.00 $2,040.00 $680.55 

REMOVAL OF CALCULUS 

(/ 47480 1 CHOLECYSTOTOMY WITH EXPLORATION, ETC. (SEP PROC) 1 3 1 $1,771.35 I $1,300.36 I $9.00 I I I $500.00 

47600 CHOLECYSTECTOMY 4 31J72.15 $2,836.80 $287.50 $2,003.30 $64.20 

47605 CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY 5 $1,4S6.00 $4,081.50 $998.35 SlJ24.12 $57.10 

47610 CHOLECYSTECTOMY, EXPLORATION OF COMMON DUCT 2 $321.00 $1,687.30 $259.20 $400.00 $300.00 

47720 CHOLECYSTOENTEROSTOMY; DIRECT 2 $623.60 $1,795.00 $2S5.50 

II 47760 1 ANASTOMOSIS. DIRECT. EXTRAHEPATIC DUCTS & GI TRACT I 1 I I S677.45 1 s306.66 S1.067.00 I I 

44300 I ENTEROSTOMY, OR CECOSTOMY, TUBE (SEP PROC) I 2 I $1,077.30 $868.00 I $264.00 I 

I 

/I48540 INT ANASTOMOSIS, PANCREATIC CYST TO GI TRACT; I 

1 

I I 

SL245.00 $552.40 $510.70 IROUX-EN-Y I

II49020 I DRAINAGE OF PERITONEAL ABCESS, TRANSABDOMINAL I 5 I $1,243.80 $1,703.45 I $1,656.65 1 $133.06 I 

II49200 / EXCISE, DESTRUCT INTRA-ABDOMINAL TUMORS, CYSTS, ETC. 1 2 1 $810.00 $1,249.00 I I I $103.20 

II49220 I STAGING LAP FOR HODGKIN’S DISEASE OR LYMPHOMA I 1 I $543.20 1 %l,ooo.oo I I I I

II49505 I REPAIR INGUINAL HERNIA I 2 I I $778.85 1 I $898.50 $110.86 I 

II49560 I REPAIR INCISIONAL HERNIA (SEP PROC) I 2 I $321.00 $1,082.55 / $66.34 I $1,019.10 I 

II49565 I REPAIR INCISIONAL HERNIA, RECURRENT I 1 I I $319.40 I I I $149.10 $319.40 

A-3 
49999 UNLISTED PROC, ABDOMEN, PERITONEUM AND OMENTUM 2 $855.70 $408.85 $177.36 $128.30 

50230 NEPHRECTOMY, RADICAL, REGIONAL LYMPHADENECTOMY 1 $638.80 $1306.20 

50390 ASPIRATION &/OR INJECTION, RENAL CYST, PERCUTANEOUS 1 $l,OOO.OO $51.75 $200.00 

50800 URETEROENTEROSTOMY; UNILATERAL 1 $294.10 $992.00 $58.80 

51550 CYSTECTOMY, PARTIAL; SIMPLE 1 $320.90 $929.90 

51840 ANTERIOR VESICOURETHOPEXY 1 $853.00 $1,191.80 $400.00 

(MARSHALL-MARCHETTI-KRANTZ); SIMPLE 

51841 ANTERIOR VESICOURETHOPEXY; COMPLICATED (e.g., 1 $320.90 $705.90 

SECONDARY REPAIR) 

58150 TOTAL ABDOMINAL HYSTERECTOMY, WITH/WITHOUT 9 $4,678.08 $10,213.40 $1,200.00 

SALPINGO-OOPHORECTOMY 

58210 RADICAL HYSTERECTOMY 1 $2,231.60 $107.10 

58720 SALPINGO-OOPHORECTOMY, UNI- OR BILATERAL, SEP PROC 4 $1,985.50 $3,839.04 $356.50 

58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL 1 $337.50 $844.25 

OR BILATERAL 

58925 OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL 2 $260.45 $1,008.50 $1347.85 

58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR 3 $1,433.40 $1,559.50 $388.15 $778.00 

BILATERAL 

58950 RESECTION OF OVARIAN Ca WITH 2 $600.00 5LO16.35 $487.50 $1,417.35 

SALPINGO-OOPHORECTOMY & OMENTECTOMY 

58951 RESECTION OF OVARIAN Ca WITH TOTAL ABDOMINAL 1 $582.00 $1365.00 

HYSTERECTOMY 

141 S39,637.44 $115,713.17 $5,957.29 $26,426.32 $5902.92 $11255.94 

A-4 
49010 EXPLORATION, RETROPERINEUM, OBS DENY ALLOW ALLOW DENY DENY 

II I WITH OR WITHOUT BIOPSY(S), I I LAPAROTOMY, PRINCIPAL SECONDARY “SEPARATE 1 SECONDARY 11 

II I SEPARATE PROCEDURE I I SURGEON PROCEDURE PROCEDURE PROCEDURE” 1 PROCEDURE 11 

I

LIMITED LYMPHADENECTOMY, FOR STAGING (SEPARATE I 1I $275.00 $411.50 I II 38564 PROCEDURE)$lCKMOII

II 38100I SPLENECI-OMY (SEPARATE PROCEDURE); TOTAL I 1 I $200.00 I $800.00 I I II 

II 43820 I GASTROJEJUNOSTOMY I 1 I $1,500.00 $800.00 $437.50 I II .. 43832 GASTROSTOMY, PERMANENT, WITH CONSTRUCTION OF 1 $730.00 $859.80 

GASTRIC TUBE 

49200 EXCISION OR DESTRUCTION OF INTRA-ABDOMINAL 1 $532.39 $974.40 S782.20 

TUMORS, CYSTS, ETC. 

49530 REPAIR INGUINAL HERNIA. INCARCERATED 1 $300.00 S667.00 

I

TOTAL ABDOMINAL HYSTERECTOMY, WITH/WITHOUT 1 $450.00 $895.80 II 58150 SALPINGO-OOPHORECTOMY I I I I II

II 58200 1 TOTAL HYSTERECTOMY, INC. PARTIAL VAGINECTOMY I 1 I $250.00 1 $1,190.00 1 I $75.00 / II 

II 22842 j REMOVAL OF SPINAL INSTRUMENT I 1 I J1600.00 I $3307.50 1 I I $1,828.20 11 

II I I 9 I $5,837.30 $9906.00 I $437.50 $175.00 $2,610.40 11 

A-5 
APPENDIX B 

Overpayments associated with code 19101, Biopy of breast, inctinal and with code 

85102, Bone mun-ow needle biopsy 

B-l 
B-2 
/I 85102 1 BONE MARROW NEEDLE BIOPSY I OBS 1 DENY I ALLOW I ALLOW I DENY 

BIOPSY, PRINCIPLE SECONDARY BIOPSY, 

SURGEON PROCEDURE PROCEDURE LABORATORY 

II 20220 I BONE BIOPSY, NEEDLE, SUPERFICIAL I 9 I $357.00 I $754.30 1 I $336.13 

II 20225 I BONE BIOPSY, NEEDLE, DEEP I 5 I I $420.40 1 $110.55 1 $230.90 

II 20245 I BONE BIOPSY, EXCISIONAL, DEEP I 1 I $84.60 1 $72.00 / I 

II 27447 I TOTAL KNEE REPLACEMENT I 1 I I $2,853.54 I $82.90 

II 85095 I BONE MARROW SMEAR, ASPIRATION ONLY I %I $7,014.05 I $4,164.63 1 I $81.00 

85100 BONE MARROW SMEAR, ASPIRATION, II IINTERPRETATION STAINING & 18 I I SlJO7.65 $1,937.10 I 

85101 BONE MARROW SMEAR, ASPIRATION & STAINING 1 $130.00 $90.00 

121 $8,693.30 $10,291.97 $110.55 $730.93 

B-3 
APPENDIX C 

Overpayments associiated with code 47100, Biopy of liver, wedge (separate procedure) 

and with cock 48100, Biopsy of pancreas (separate procedure) 

C-l 
Morning Report: 2 Ye8 - No 

Title: Implementation of State Child Support Certified Data 

Systems 

Reference: OEI-04-96-00010 Contact: Mary Beth Clarke 

(202) 619-2481 

We released a final report on implementation of State child 

support certified data systems. States appear to be well 

positioned to get their systems certified by the October 1, 

1997 deadline. At the time of our review, six States had 

certified data systems. Forty-two States and territories 

anticipate having their systems certified by the deadline. 

Most States attributed implementation delays largely to a 

requirement to share technology, short time frames, and 

ineffective State and contractor working relationships. 

Despite the favorable outlook, continuing attention will be 

needed to ensure success. We recommended that ACF continuously 

monitor the status of each State's progress, provide technical 

assistance to States having difficulty meeting the revised 

deadline, and continue to monitor and provide technical 

assistance to States as they prepare to develop additional data 

systems required by the Personal Responsibility and Work 

Opportunity Reconciliation Act of 1996. The ACF agreed with 

our recommendations.