Cardiovascular stress testing to diagnose patients with coronary artery disease (CAD) and other related types of conditions can be a highly-effective tool in many cases. In fact, many cardiologists routinely recommend stress testing for patients who present with risk factors or who are showing possible symptoms of CAD, and stress testing can be a necessary supplement to electrocardiograph or radionuclide imaging in many instances.
However, cardiovascular stress testing has also proven to be a high-risk area for Medicare fraud. Due to the prevalence of heart disease and the nature of cardiovascular stress testing, this testing has proven extremely popular in recent years—so much so that it has caused federal authorities to sound the alarm. Cardiovascular stress testing fraud is now a top priority for federal authorities nationwide, and the Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), and U.S. Department of Justice (DOJ) are all aggressively targeting providers suspected of fraudulently billing Medicare for these tests.
“Billing Medicare for cardiovascular stress testing presents significant risks for health care providers. Federal authorities are currently prioritizing enforcement in this area, and health care providers accused of fraudulently billing Medicare for cardiovascular stress testing can face exposure to substantial liability.” – Dr. Nick Oberheiden, Founding Attorney of Oberheiden P.C.
When is Cardiovascular Stress Testing Covered Under Medicare?
Due to the fact that CMS, the HHS OIG, and the DOJ are all targeting health care providers that bill Medicare for cardiovascular stress testing, providers that offer these services to their patients need to be absolutely certain that their billing practices are compliant. They must also take adequate measures to document their compliance efforts, as it may become necessary to provide this documentation to auditors, agents, or prosecutors in the event of a federal inquiry.
However, establishing Medicare billing compliance with regard to cardiovascular stress testing is not necessarily as straightforward as it may seem. The Centers for Medicare and Medicaid Services have issued multiple local coverage determinations (LCDs) for cardiovascular stress testing, and following these LCDs can prove challenging even for providers and billing administrators who are well-versed in the Medicare billing system.
For example, LCD L34324 (titled Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography) provides a general overview of Medicare coverage for cardiovascular stress testing. It states that “[a] cardiovascular stress test is covered for a patient who” meets one or more of five specified criteria. These criteria are:
- Exhibiting signs or symptoms of CAD (angina pectoris or anginal equivalent symptoms, cardiac rhythm disturbances, unexplained syncope, heart failure, or significant atherosclerotic vascular disease elsewhere in the body);
- Being diagnosed with a metabolic disorder known to cause CAD (diabetes mellitus, Syndrome X, or atherogenic hypercholesterolemia);
- Having an abnormal ECG consistent with CAD;
- Needing evaluation “as part of a preoperative assessment when intermediate- or high-risk for CAD is present and surgery is likely to induce significant cardiac stress”; and/or,
- Needing evaluation “when information from the clinical assessment does not adequately assess functional capacity when such information is needed to manage the patient . . . .”
However, LCD L34324 then goes on to list several circumstances in which cardiovascular stress testing is not considered “reasonable and necessary”—and therefore is not eligible for Medicare reimbursement. For example, even if a patient meets one or more of the criteria listed above, cardiovascular stress testing is not covered when:
- “The incremental information obtained from a repeat test or from the addition of an echocardiogram to an electrical stress test is of no clinical relevance.
- “The results of the test have no potential to affect the treatment of the patient, such as when the patient has a severe comorbidity that is likely to limit life expectancy and/or likely to limit his/her candidacy for revascularization.
- “Secondary conditions will potentially decrease both the sensitivity and specificity of testing (e.g., immediate postoperative period, anemia, or infection).
- “A stress test is performed too frequently . . . .
- “[Used f]or screening CAD . . .
- “[U]sed solely to motivate changes in lifestyle.
- “To qualify a patient for a noncovered service, such as fitness training, a weight loss program, or an occupational fitness evaluation.
- “For a preoperative assessment prior to either a noncovered surgery or a covered surgery if the reasonable and necessary criteria for the testing is not documented.”
Then, there is LCD L38396 (titled Cardiology Non-emergent Outpatient Stress Testing). This local coverage determination addresses the Medicare eligibility of cardiovascular stress testing in the outpatient setting. LCD L38396 lists nine specific circumstances in which cardiovascular stress testing without cardiac imaging will be considered “reasonable and necessary” for Medicare reimbursement purposes and 21 specific circumstances in which cardiovascular stress testing with imaging is eligible for reimbursement. It then lists 14 “limitations” that make cardiovascular stress testing ineligible for reimbursement with or without cardiac imaging. While some of these limitations overlap with those in LCD L34324, there are notable differences between the lists of limitations in these LCDs (and other LCDs that apply to cardiovascular stress testing) as well.
Many of the limitations in LCD L34324 and LCD L38396 will be triggered by other decisions made regarding a patient’s care—not only in the past, but also potentially in the future. For example, LCD 38396 states that cardiovascular stress testing is not considered medically reasonable and necessary when the results of the testing, “will not affect patient management decisions.” This is a highly subjective analysis, and providers must devote the necessary time and resources to ensuring that they document the justification for all tests they perform in order to withstand scrutiny during a Medicare audit or billing fraud investigation.
3 Keys to Maintaining Medicare Billing Compliance with Regard to Cardiovascular Stress Testing
Given the challenges and risks associated with billing Medicare for cardiovascular stress testing, providers that bill for these tests must take exhaustive measures to ensure compliance on an ongoing basis. This is particularly important with enforcement in this area being a top priority for CMS, the HHS OIG, and the DOJ. In order to avoid raising red flags and emerge from an audit or investigation unscathed, some of the key steps providers need to take include:
1. Identify and Apply All Relevant Medicare Billing Rules and Guidelines
It is imperative for health care providers that perform cardiovascular stress testing to identify and apply all relevant Medicare billing rules and guidelines. The rules and guidelines from LCD L34324 and LCD L38396 summarized above provide just a small sampling of what providers need to know. However, these examples illustrate the complexity and particularity of the restrictions that are in place, and providers must devote the time and resources necessary to ensure that their Medicare billing practices are fully compliant on an ongoing basis.
2. Follow Custom-Tailored Medicare Billing Compliance Policies and Procedures
Providers that bill Medicare for cardiovascular stress testing must follow custom-tailored billing compliance policies and procedures. These policies and procedures must address all pertinent rules and regulations, and they must do so in a way that facilitates compliance within the context of their unique operations. Too often, health care providers rely on off-the-shelf compliance programs purchased from vendors, and in doing so they fail to address the specific risks they face on a day-to-day basis.
If a provider’s Medicare billing compliance policies and procedures do not address the provider’s specific risks, then they are not going to serve their intended purpose. This is particularly true with regard to nuanced areas of compliance such as cardiovascular stress testing. Providers will make mistakes, and they will face adverse consequences as a result.
3. Document the Medical Necessity of All Cardiovascular Stress Tests and Related Services
As mentioned above, maintaining adequate documentation is critical for demonstrating compliance in the event of a Medicare audit or billing fraud investigation. With regard to cardiovascular stress testing, documentation of medical necessity is particularly important. In order to avoid allegations of fraudulently billing Medicare for excessive and unnecessary tests, providers must be able to demonstrate (with documentation) that they have affirmatively considered the eligibility criteria for these tests. Even if a cardiovascular stress test is eligible based on the reason for which it was conducted, if a provider cannot substantiate this reasoning, it could still face liability for recoupments and other penalties.
Now is the Time for Health Care Providers to Reevaluate Their Medicare Billing Compliance Efforts
With CMS, the HHS OIG, and the DOJ all cracking down on Medicare billing fraud related to cardiovascular stress testing, now is the time for health care providers to reevaluate their compliance programs. Providers should work with their legal counsel to ensure that their policies and procedures align with CMS’s latest guidance, and they should audit their past stress test billings for any potential mistakes. If a provider’s policies and procedures are inadequate or mistakes have been made, addressing the issue proactively—before auditors or agents come knocking—will help ensure that any adverse consequences are no greater than necessary.