Audit of Medicaid Claims for Services Identified as Mutually Exclusive Procedure Codes at The Michigan

0 Department of Health and Human Services OFFICE OF INSPECTOR GENERAL AUDIT OF MEDICAID CLAIMS FOR SERVICES IDENTIFIED AS MUTUALLY EXCLUSIVE PROCEDURES CODES AT THE OF COMMUNITY HEALTH JANUARY THROUGH JUNE GIBBS BROWN Inspector General JUNE 200 A-05-00-00006 SEPTEMBER June 15, 2000 Common Identification No. A-05-00-00006 James DirectorDepartment of Community ServicesLewis Cass Building300 South Walnut StreetLansing, MI 48913Dear Mr. This final letter report presents the results of our Audit of Medicaid Claims for Services Identified as Mutually Exclusive Procedure Codes. The objective of our review was to determine the extent of potential overpayments or savings that could accrue to the Federal government and the State of Michigan if edits were implemented to identify and deny payments for procedure codes that the Health Care Financing Administration (HCFA) has identified as mutually exclusive. We determined that the State agency currently has edits in place that require pre-defined combinations of procedure codes to be reviewed before payment is made. However, thesecombinatorial edits did not include all of the procedure codes that HCFA has identified asmutually exclusive.We have recommended that the State agency implement appropriate edits that will identify and deny claims for procedure codes identified by HCFA as mutually exclusive. Based on our reviewof payments for radiology and laboratory services made during our ...