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Monitor Potential FWA: Overutilization of High-Level Codes

  • by Steve Nesnidal, MD, CPC, AHFI
  • Sep 13, 2023, 11:24 AM
Monitoring Claims for Fraud-canstockphoto25652629

A common Fraud, Waste and Abuse (FWA) pattern detection involves monitoring for and analyzing data of providers that consistently submit claims for the highest reimbursable code within a given procedure code group.  Once detected, a focused audit will allow an investigator to see if medical records support or do not support the high frequency of high dollar claim submissions.

For example, take the definitive drug testing group of HCPCS codes G0480-G0483. A recent OIG report1 found that Medicare as a payer could have saved $216 million over a 5-year period by monitoring providers who frequently billed the highest reimbursable HCPCS G0483. Below is the list of codes for definitive drug testing and their 2023 Clinical Laboratory Fee Schedule reimbursement amounts.

Code              Code Description                      2023 Fee
G0480             Drug test def 1-7 classes            $114.43
G0481             Drug test def 8-14 classes          $156.59
G0482             Drug test def 15-21 classes        $198.74
G0483             Drug test def 22+ classes           $246.92

In their audit of similar types of providers that tested similar types of patients with similar frequency, the OIG found a subset of providers billed G0483 at a higher frequency. Upon auditing those providers, the OIG found that drug classes were being miscounted by some providers. For example, a provider counted the benzodiazepines it tested as one drug class based on CPT guidance while another provider counted each of the 13 benzodiazepines it tested as 13 separate drug classes. A provider error such as miscounting of drug classes can lead to upcoding to a higher level code, leading to a higher reimbursement that was not actually owed to the provider.

Another example of a code group known to be submitted at a high frequency using unsupported high-level codes is the Tier 2 molecular pathology procedure code (MPP) group. According to an OIG audit released in June 20232, the genetic-testing CPT code 81408, the code in this group with the highest Medicare payment amount ($2,000), had the second highest total Part B payments for dates of service (DOS) from 2018 through 2021.  This is not logical, considering Tier 2 procedures are used to test for relatively rare diseases.  The OIG determined over 888 million dollars paid by Medicare were at risk for improper payment in this interval.  Context4 Healthcare (C4H) recommends that all Health Plans monitor provider frequency of high level of Tier 2 Genetic Testing codes.

C4H offers a series of FWA Reports that assist the user in detecting the provider that submits unusually high frequency of high-level codes within a given code group. Several of our Reports can assist with this type of analysis, including our Most Frequent Procedure Report, Highest Charge Procedure Report, Most Frequent E/M Encounters Rank, as well as our Provider High Volume Data Mining Reports. Effective FWA software should not only detect aberrant patterns of fraud in claims data, but it must also effectively allow the user to analyze claims submitted by that provider who submits atypically high-level codes.  The user who identifies atypically high frequency can then take the next step and review a sample of related medical records.

A detailed audit of the related medical records will determine whether or not an atypically high code level submitted by a given provider is supported.  This type of audit can also reveal other secondary fraud patterns, like a high frequency of associated procedure code submission.  When one red flag leads to other secondary flags, the likelihood of fraud rises. 

The two examples mentioned above direct Health Plans to monitor these specific laboratory code groups, but this pattern of FWA abuse of high-level codes can also be found in the Evaluation and Management (E/M) code groups, as well as code groups in the Medicine section of CPT, and in various HCPCS code groups also.  C4H’s suite of software edits detects multiple types of code level discrepancies at the claim level.  Our FWA Reports analyze batches of claims for high level code abuse, allowing the user to select the key report parameters of interest, including code(s), DOS, and provider.  This allows our user to scrutinize claims data from multiple angles, the optimal approach to monitor for fraud.

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


  1. https://oig.hhs.gov/oas/reports/region9/92103006.pdf
  2. https://oig.hhs.gov/oas/reports/region9/92203010.pdf
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