In March of 2026, the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) released an audit findings report on Emergency Department procedure codes used on Medicare claims for services billed with nonemergency department sites of service.The OIG determined this issue was responsible for over $15 million in potentially improper payments. Of that $15 million in improper payments, Medicare incorrectly paid physicians/qualified healthcare providers (QHP) for 9,749 procedures totaling $922,524 when providers billed for emergency department procedures with nonemergency Place of Service (POS) codes.1 In support of this audit, OIG cited the Medicare Claims Processing Manual Chapter 12, which states: “Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any [site] of service other than an emergency department.”2

Medicare requires that physician/QHP provider claims using Emergency Department procedure codes 99281-99285, and G0380-G0384 to be submitted with an emergency room POS code. In their audit, the OIG cited the most frequently submitted inappropriate POS codes as POS 21 (inpatient hospital), POS 22 (on-campus outpatient hospital), and POS 49 (independent clinic).  Context4 Healthcare (C4H) recommends all health plans follow Medicare guidance on this.  All plans should monitor claims for emergency department procedure codes associated with nonemergency POS codes. C4H also recommends each health plan clearly documents the emergency department policy that best suits the plan.

Emergency department claims improperly submitted can add up to millions of dollars, as demonstrated by this OIG audit.  Let C4H help you detect this. We provide our users with edits that fire on claims with inappropriate procedure code/POS combinations. C4H recommends all Health Plans have means to detect such inappropriate billing patterns, to protect against payment for emergency department services performed in non-Emergency Department places of service.

For more information about CONTEXT4 HEALTH PLANS SUITE™ which contains a full spectrum of up-to-date claims edits, view our webpage at this link: https://www.context4healthcare.com/health-industries/payers

References

  1. https://oig.hhs.gov/documents/audit/11499/A-07-23-05139.pdf
  2. CMS Claims Manual, Chapter 12, Section 30.6.11 (B).