Guide
Top Medicaid Billing Codes
The 10 highest-spending HCPCS procedure codes in Medicaid, what they mean in plain English, and which ones carry the highest fraud risk.
Personal Care Services (per 15 min)
$86.90B
28,000 providers
Largest single code by spending. Dominated by NYC home care agencies. High fraud risk due to difficulty verifying in-home services. Read investigation →
Personal Care Services (per diem)
$13.10B
4,200 providers
Per-diem version of personal care. Large billing per claim makes outliers more impactful.
Office Visit, Established Patient (Low-Mod)
$7.20B
120,000 providers
Most commonly billed office visit code. Extremely high volume but low per-claim cost makes fraud less impactful per instance.
Habilitation, Residential (per diem)
$6.80B
3,100 providers
Massachusetts DDS entities bill 37-51× the national median for this code. One of our highest-confidence fraud signals.
Office Visit, Established Patient (Mod-High)
$5.90B
95,000 providers
Second most common office visit code. Often scrutinized for upcoding from 99213.
COVID-19 Testing (Infectious Agent Detection)
$3.90B
15,000 providers
Generated $3.9B during the pandemic. Some providers billed extraordinary volumes. LabCorp alone: $174M. Read investigation →
Attendant Care Services (per diem)
$3.20B
2,800 providers
Home-based attendant care. Similar fraud risks to T1019 — difficulty verifying services delivered in private settings.
Nusinersen (Spinraza) Injection
$1.80B
450 providers
The most expensive single procedure at $92,158 per claim. Legitimate specialty drug for spinal muscular atrophy. High cost reflects drug pricing, not fraud. Read investigation →
Comprehensive Community Support (per 15 min)
$1.50B
4,800 providers
Community-based behavioral health services. Wide variation in billing rates across states and provider types.
Ambulance, Advanced Life Support (Emergency)
$1.20B
8,500 providers
Emergency ambulance transport. City of Chicago bills $1,611 per trip vs $163 national median — a 10× outlier.
Related Guides
Understanding HCPCS Codes
What billing codes mean, how they're structured, and which ones are most associated with fraud.
How Medicaid Fraud Works
Common schemes, red flags, and how data analysis can detect them.
How to Read a Medicaid Billing Record
Understand NPIs, claims, beneficiaries, and what the numbers mean on provider profiles.
Medicaid Fraud by State
Which states have the most flagged providers and biggest spending anomalies.