Audit uncovers coding issues for EEG submissions

OIG auditors reviewed 30 claims for ambulatory electroencephalograms (EEG) submitted by Memorial Hermann Health System (Memorial Hermann) and found that the provider did not always comply with select program rules. The audit reviewed encounters with Medicaid clients from September 2019 through August 2021.

Auditors found that half of the tested encounters were submitted without an allowable diagnosis code. Diagnosis codes allow providers to quickly summarize a client's health condition using a nationally accepted set of codes that communicate information with other providers and payers like Medicaid. When these codes are not provided, a patient's medical records at the insurer can be incomplete, leading to incorrect reimbursement for a provider.

Memorial Hermann was able to provide auditors with supporting documentation for all 15 of the encounters, which showed that the ambulatory EEG was performed and that proper procedure codes were submitted to Medicaid. Procedure codes, unlike diagnosis codes, represent what services were delivered by the provider to treat the client's condition.

The OIG recommended Memorial Hermann develop a process to validate that submitted claims comply with all rules and regulations and verify that diagnosis codes are included.