Case of the Month: False Billing of Nuclear Stress Tests at Center of $50 Million Cardio Fraud Scheme

The feds arrested a cardiologist, neurologist and four others for their role in an elaborate fraud scheme. The government contends that over a 12- year period, the defendants’ New York City medical practice billed Medicare and private insurers for $50+ million worth of cardiology and neurology tests and procedures that were either medically unnecessary or not actually provided, including nuclear stress tests (NSTs) on patients who didn’t need them. In addition to prison time, the defendants face the risk of treble damages and civil penalties under the False Claims Act.

NST Billing & Coding
NSTs measure blood flow to the heart both when the patient is resting and stressed (either via exercise or chemical inducement). There are three possible CPT codes for billing the imaging part of the test:

• Codes 78451 (SPECT) when only one set of images is taken, either at rest or stress;

• Code 78543 (Planar) when only one set of images is taken, either at rest or stress; and

• Code 78452 may only be used when two sets of images are taken.

Lack of MD Options in Superbill
The problem was that the practice listed only one code for “Nuclear Studies” in its superbill: 78452. The result was that physicians were forced to indicate that they performed both a resting and stress study, even if they actually performed only one part of the study.

Takeaway: Although the case involved cardiology testing, the same “bundling” risks arise in physician ordering of laboratory tests, particularly with regard to test panels. To avoid “bundling” charges, labs must ensure that their requisition forms list not just the test panel but the component tests it contains so that the physician has the option of ordering the test(s) individually.