From the public record · not a Soft Home Global client
Modifier 59 on right heart catheterizations: what OIG found at The Ohio State University Hospital
When the second procedure is an inherent part of the first. At The Ohio State University Hospital, OIG found modifier 59 appended to right heart catheterizations performed in the same encounter as heart biopsies on 13 of 22 sampled outpatient claims. The biopsy was the primary purpose of the catheterization, so the catheterization was not a distinct service and the biopsy payment already covered it.
This is a summary of a published audit by the HHS Office of Inspector General. The Ohio State University Hospital is not a client of Soft Home Global, and Soft Home Global had no part in the audit. Every figure is quoted from the report, which is linked below — read it rather than rely on this page. Where The Ohio State University Hospital disputed a finding, that is shown too: these are audit findings, not a court’s verdict.
The audit
What went wrong, claim type by claim type
Modifier 59 on right heart catheterizations
13 of 22 outpatient claims · $10,723
Right heart catheterizations were billed with modifier 59 as separate and distinct from heart biopsies done in the same encounter. The medical records showed the biopsy was the primary purpose of the catheterization, so the catheterization was an inherent component of the biopsy.
Why, per the report: Hospital officials agreed the claims were billed in error "due to their interpretation of the indicators of when it was appropriate to assign modifier 59."
HCPCS codes not supported by the medical record
5 of 22 outpatient claims · $28,633
Outpatient claims carried HCPCS codes the records did not support.
Why, per the report: The Hospital stated these were missed because its outlier audits reviewed only inpatient claims.
Multiple units on outpatient surgery
3 of 22 outpatient claims · $4,478 (net)
Outpatient surgery procedures were billed with multiple units when one unit should have been billed.
Why, per the report: Hospital officials stated that "a control edit was inadvertently disabled."
Incorrect DRG codes
8 of 123 inpatient claims · $84,777 (net)
Incorrect diagnosis codes were used to derive the DRG, producing payments higher or lower than they should have been.
Why, per the report: The Hospital stated the claims were "inadvertently coded incorrectly due to human error."
Inpatient rehabilitation that did not meet Medicare criteria
15 of 123 inpatient claims · $184,833 (net)
Twelve stays did not meet the reasonable-and-necessary criteria for intensive rehabilitation; three were coded to the wrong case-mix group.
Why, per the report: The Hospital did not give a cause, maintaining most claims met requirements.
Billed as inpatient instead of outpatient or observation
3 of 123 inpatient claims · $22,388
Stays did not meet Medicare criteria for inpatient status under the two-midnight expectation in 42 CFR § 412.3.
Why, per the report: The Hospital maintained the records supported medical necessity.
How it was to be resolved
OIG recommended that The Ohio State University Hospital:
- Refund the estimated overpayments for incorrectly billed services within the 4-year reopening period
- Exercise reasonable diligence to identify, report and return overpayments under the 60-day rule
- Strengthen controls to ensure full compliance with Medicare requirements
What The Ohio State University Hospital said: The Hospital disagreed with most findings and with the extrapolation method, but agreed with some sampled errors and repaid Medicare $396,025.
What a practice or billing team can take from it
These points are Soft Home Global’s reading of the report, not OIG’s words.
- Modifier 59 (and its X{EPSU} subsets) says a service was genuinely separate. If the second procedure was performed to accomplish the first, it is not separate, whatever the edit allows.
- An outlier audit that only samples inpatient claims will not find outpatient coding errors. Review where the money is billed, not only where it is largest.
- A DRG is only as right as the diagnosis codes under it. Human error in code selection moves the payment in both directions.
- A billing edit that is switched off fails silently. Three surgery claims went out with the wrong units because an edit had been inadvertently disabled.
Questions
When is modifier 59 not allowed?
When the second procedure is an inherent part of the first. At The Ohio State University Hospital, OIG found modifier 59 appended to right heart catheterizations performed in the same encounter as heart biopsies on 13 of 22 sampled outpatient claims. The biopsy was the primary purpose of the catheterization, so the catheterization was not a distinct service and the biopsy payment already covered it.
Is The Ohio State University Hospital a Soft Home Global client?
No. This page summarises a public audit report published by the HHS Office of Inspector General (report A-05-18-00042, issued 22 May 2020). Soft Home Global had no involvement with The Ohio State University Hospital or with the audit.
Did The Ohio State University Hospital agree with the findings?
The Hospital disagreed with most findings and with the extrapolation method, but agreed with some sampled errors and repaid Medicare $396,025.
Source
Figures read from the report on 15 September 2026.
Next step
Would your claims pass the same review?
Send a ninety-day denial report and an aged AR summary, with no patient identifiers. Within two working days you get a written summary of which denial reasons are costing you most and what is recoverable.
Or write to ops@softhomeglobal.com