Medicare audits of two diagnostic tests—transthoracic echocardiograms and peripheral venous examinations—may point to a trend of claim denials of diagnostic tests performed to screen patients in ways that seem to fall outside a local coverage determination (LCD).
Recovery audit contractors (RACs) and several Medicare administrative contractors (MACs) are auditing transthoracic echocardiography under Targeted Probe and Educate (TPE) and at least one MAC is auditing venous ultrasounds under TPE. The overarching message is that claims will be denied when the tests are performed in the absence of signs/symptoms or other findings, said Jeanne Owens, the internal billing compliance consultant for an Illinois health system.
Both the RAC and the MAC have audited hospitals in her system. “We are getting denials and the money is being recouped,” Owens said. She thinks auditors are focusing on services that are often ordered for screening but aren’t covered under Sec. 1862(a)(1)(A) of the Social Security Act,” which says Medicare doesn’t pay for items or services that aren’t “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Only certain screening tests are covered, such as colonoscopy.
“The hardest part is going back to physicians and explaining that Medicare doesn’t cover preventive services,” Owens said. The minute the physician is performing the diagnostic test “just to be sure” or “just in case,” it’s probably in a noncovered category, she explained. “But there can be gray areas whether they’re preventive.”
Transthoracic echocardiography is the “ultrasonic examination of the heart through the chest wall,” according to LCD 33577.[1] “Echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial structure and function.”
The LCD has 15 limitations. The first states that performing echocardiography for screening isn’t covered. “A screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When the result of the test is abnormal, subsequent services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition.”
Indications two through 15 are considered medically unnecessary and therefore not payable. Among other indications are “Routine (yearly) evaluation of asymptomatic patients with corrected ASD, VSD or PDA more than one year after successful correction;” “Routine (yearly) re-evaluation of mitral valve prolapse in patients with no or mild mitral regurgitation and no change in clinical status;” and “Routine (yearly) evaluation of a patient with a prosthetic valve in whom there is no suspicion of valvular dysfunction and no change in clinical status.”
RAC Seems Focused on Annual Tests
It looks like the RAC is zeroing in on patients who are coming in every year for transthoracic echocardiograms, Owens said. “When auditors see repeat echos a year apart, they’re looking at whether the patient is asymptomatic and it’s been more than a year since their valve surgery,” for example, she said. If the patient complains about chest pain, Medicare may cover the test if the physician is trying to diagnose a sign or symptom. But they won’t cover the test to constantly monitor the patient in the absence of signs and symptoms.
Asymptomatic patients will be on the hook financially for the echo. Although patients should be informed, Owens said an advance beneficiary notice (ABN) is voluntary because screening tests are statutorily excluded from Medicare coverage. If hospitals perform the test and give patients an ABN, they should bill Medicare with modifier GY, which tells CMS the services were statutorily excluded and shouldn’t be reimbursed by Medicare.
D/dimer Tests Shouldn’t Be a Pretext
In the audit of venous ultrasounds, Owens said her hospital faced claims denials after a TPE by the MAC, National Government Services.
LCD 33627 puts peripheral venous examinations into three buckets:[2]
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Deep vein thrombosis (DVT). “These studies are rarely considered medically necessary for the following: Bilateral limb edema in the presence of signs and/or symptoms of congestive heart failure, exogenous obesity and/or arthritis; and/or Follow-up of phlebitis unless signs/symptoms suggest possible extension of thrombus.”
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Chronic venous insufficiency.
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Vein mapping.
For example, Owens said she has seen physicians order a D/dimer, a blood-clot test, for asymptomatic patients and use the results as the basis for venous ultrasounds. Or physicians may perform follow-up ultrasounds post-DVT to get a baseline reading in case the patient experiences symptoms of DVT in the future.
“If they’re doing it just to get a baseline testing or D/dimer testing or as a follow-up when no signs or symptoms exist to make sure everything is fine, Medicare is putting that into a preventive category,” she said.
Contact Owens at jeanneowenschc@gmail.com.
