Payers need to be ever vigilant in watching out for evolving fraud schemes. Case in point is a recent healthcare fraud investigation where a cardiologist was convicted of performing unnecessary cardiac procedures and causing unnecessary coronary artery bypass surgeries, which resulted in Medicare and other insurers overpaying $7.2 million over a six-year period.¹ This scheme was particularly dangerous because it not only cost taxpayers a large sum of money, but the health and lives of this doctor’s patients were needlessly jeopardized.

The procedures that were fraudulently performed and billed were nuclear stress tests, cardiaccatheterizations, and cardiacstents.

Nuclear stress tests are used to evaluate blood flow to the heart and can be done while a patient is resting and/or when the patient is active. Radioactive substance is injected into a vein and a gamma camera takes pictures of the patient’s heart. The test can detect blocked and partially blocked cardiac arteries. Single-photon emission computerized tomography (SPECT) scans are a type of nuclear imaging test and use radioactive substance with a special camera for 3-D pictures. Coding for these studies is as below:

CPT® Code	Description
78451	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78452	Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
78453	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78454	Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

Cardiac catheterization is a procedure that is used to evaluate heart function and can both detect and/or treat cardiac conditions. During the procedure, a thin catheter is inserted into a large blood vessel usually in the groin and threaded to the heart where diagnostic tests or further treatment procedures can be done. The CPT^® codes used to describe and report these procedures are 93451 – 93461.

Cardiac stenting procedures are done to provide support to the inside of a cardiac artery. An angioplasty is done prior to the stenting procedure where a small balloon is inserted into a blocked artery. After the balloon is inflated to stretch the artery, it is then deflated and a stent is inserted in the artery to keep it from narrowing. The stent stays inside the artery permanently to hold the artery open and improve blood flow to the heart. The CPT^® codes describing these procedures are 92920 – 92944, depending on the procedures done in conjunction with the stenting.

Payers can search for abnormal patterns in the billing of these procedures and investigate suspicious cases further with a review of medical records. To detect activity as described in this fraudulent scheme, a review of medical necessity for the billed procedure would be warranted for providers with abnormal activity on these billing codes.

What resources are available in order to identify potentially fraudulent and unnecessary cardiac procedures? Context⁴ Healthcare, a leader in claim compliance, developed the FirstPass™ claim editing solution with built-in edits to help payers identify potential overutilization, and/or potential fraudulent use of codes like the ones associated with these cardiac procedures. In this case, there are specific Local Coverage Determinations (LCDs) that govern the CPT^® codes previously mentioned in this article and these LCDs are checked and referenced by specific rules within FirstPass™. With thousands of rules and millions of edit combinations updated weekly, FirstPass™ is SaaS-based with real-time web services so payers are always up-to-date with industry compliance and reimbursement standards.

In addition, those who utilize FirstPass™ can add real-time access to Context's UCR fee data derived from billions of provider charges and updated twice per year. Real-time access to FirstPass™ and  DecisionPoint™ Health Payment System (UCR fee data) will go a long way toward achieving claim compliance and real-time analysis of claims.

¹https://www.fbi.gov/cleveland/press-releases/2015/westlake-cardiologist-convicted-of-overbilling-medicare-and-others-of-7.2-million-for-unnecessary-procedures

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For related reading, check out: Detect FWA Using Patterns in Procedure & Diagnosis Code Pairings