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Understand the audit risks and penalties from some cardiology codes


How the CMS definition of cardiovascular surveillance is leading to significant recoupments from cardiology practices

Audit risks of cardiology codes: ©JohnKwan - stock.adobe.com

Audit risks of cardiology codes: ©JohnKwan - stock.adobe.com

The Centers for Medicare & Medicaid Services (CMS) has increased their scrutiny of specific cardiology codes for Transcranial Doppler (TCD) Studies of the Intracranial Arteries (CPT 93886), Vasoreactivity Studies (CPT 93890), and Emboli Detection Without Intravenous Microbubble Injection (CPT 93892). Central to these challenges is CMS’ tendency to categorize the services rendered as “routine screenings”, rather than recognizing them as surveillance tests.

The CMS is bound by Local Coverage Determinations (LCD) governing these codes, however, many times Medicare contractors ignore or misinterpret the LCD to the detriment of providers. Now, physicians performing these services are facing a heightened risk of exposure to medical audits, overpayment demands, and other potential penalties triggered by what the CMS deems to be an excessive use of the codes.

CMS oversight and preconceived notions

Despite applicable LCDs, such as LCD 33577 for Transthoracic Echocardiography (TTE), which recommends TTE studies for patients with dyspnea and clinical signs of heart disease, or LCD 33627 for Non-Invasive Vascular Studies covering the follow-up of previously documented stenoses in carotid studies, CMS often overlooks specific conditions that give rise to surveillance studies. This oversight results in generic denials that fail to acknowledge the personalized care provided by cardiologists to CMS beneficiaries.

CMS auditors frequently overlook pivotal factors, like patient histories and presenting symptoms, during their review of records, showing their inability to capture the nuanced circumstances that warrant the application of surveillance studies in cardiovascular care.

Complicating matters further, we have observed a recurring issue where CMS approaches audits with preconceived notions, predominantly categorizing practices as engaged in “routine screenings” based on the frequency of testing alone. This conduct by the CMS disregards the fact that the services involve surveillance testing directly linked to symptoms, which differs greatly from a simple routine screening.

The CMS’ auditors seem to miss the point that a screening is done in the absence of signs, symptoms, or past history necessitating the study, while surveillance is done when the patient has a history of cardiac disease requiring periodic monitoring.

Instances where patients have a history of occlusion, for example, relevant symptoms, and a condition necessitating annual monitoring are often disregarded and the services provided are mischaracterized as routine tests. Auditors’ preconceived notions regularly lead to misunderstandings and misinterpretations regarding the nature and medical necessity of potentially lifesaving tests and ultimately lead to claim denials, failed audits, and overpayment demands.

Provider challenges and risks

Our firm has witnessed highly qualified and experienced cardiologists undergoing extensive scrutiny from CMS as part of their targeted enforcement initiatives of various cardiological tests. Despite the proficiency and clinical expertise of these skilled practitioners, CMS’ inability to recognize the nuanced difference between routine screenings and surveillance studies can lead to repeated unfavorable or failed audits.

Audits that are consistently assessed as unfavorable can expose providers and their practices to serious potential repercussions. One such repercussion includes exclusion from the Medicare Program as outlined in Section 1128(b) of the Social Security Act. Providers may also face civil monetary penalties and suspension of Medicare payments in accordance with 42 C.F.R. §405.370 et seq. that can have a significant impact on the financial viability of their practice. Civil monetary penalties will result in a demand for treble damages, as well as penalties that range from $13,508 to $27,018 per claim.

Consistently failed audits can also lead to potential revocation of Medicare billing privileges under specific conditions outlined in 42 C.F.R. § 424.535. The CMS, as per 42 C.F.R. § 424.535(a)(8)(ii), has the power to revoke billing privileges for enrolled providers or suppliers if a pattern or practice is identified, wherein claims consistently fail to meet Medicare requirements. The unfavorable findings could lead to further consequences, including decredentialing, litigation under the False Claims Act, or, in the most severe cases, a criminal indictment.

Mitigating risks and safeguarding your practice

As CMS continues to focus its targeted initiative on cardiology studies, providers must remain informed and proactive in their approach to medical billing and documentation. Practices should fight every single audit and overpayment demand, regardless of how indefensible the CMS contractor’s findings letter may make it seem.Targeted audits may start with a single patient Recovery Audit Contractor (RAC) audit or a fifty patient Unified Program Integrity Contractor (UPIC) audit.Providers should treat each audit with the same seriousness and consult with health care counsel to determine the potential risk of escalation and to begin preparing for a vigorous defense.

Guillermo J. Beades, Esq., is partner in Frier Levitt’s Healthcare Litigation Department and Co-Chairs the Firm’s Insurance Defense Group. Phoebe A. Nelson, is Associate in Frier Levitt’s Healthcare Department.

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