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Potential Vulnerabilities Related to Hospitals' Billing for Drugs Different From Those That May Have Been Administered to Medicare Enrollees

Medicare requires hospitals to submit accurate claims for outpatient services, including drugs administered. Hospitals must use standardized codes, called Healthcare Common Procedure Coding System (HCPCS) codes, for drugs administered. Most National Drug Codes (NDCs), which are unique numbers used to identify drugs in the United States, are assigned to HCPCS codes. Hospitals may be billing for administered drugs using an HCPCS code different from the one assigned to the NDC reported on the claim. This means that they may be billing for drugs that were not the ones administered. We will identify ways in which Medicare is potentially vulnerable to improper payments when hospitals bill for drugs with HCPCS codes that do not match those assigned to the NDCs listed on the claims.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
July 2025 CMS Potential Vulnerabilities Related to Hospitals' Billing for Drugs Different From Those That May Have Been Administered to Medicare Enrollees Office of Audit Services OAS-25-09-090 2026