Case of the Month: Feds Turn Up the Heat on False Billing of Nuclear Stress Tests

While the feds have made urine drug testing of opioid drug patients their number one target for lab-related False Claims Act (FCA) charges this year, nuclear stress tests (NSTs) ordered by cardiologists have also been garnering increasing attention. There are three things about NSTs, which use radioactive dyes to measure blood flow to the heart both when the patient is resting and stressed either via exercise or chemical inducement, that put them high on the list of FCA enforcement priorities in the diagnostics sphere:

1. NSTs are very expensive;

2. They expose patients to significant doses of radiation; and

3. They can generate false positives resulting in the ordering of medically unnecessary invasive procedures.

Routine Ordering of NSTs: The CVC Case
For these reasons, NSTs are deemed medically necessary only in very limited circumstances. So the ordering of NSTs at abnormally high rates routine raises a bright red flag.

CVC Heart Center, a California cardiology clinic, and its physician owners just learned this lesson the hard way. The U.S. Attorney charged the defendants with falsely billing Medicare and Medicaid for medically unnecessary NSTs over a five-year period beginning in 2010. According to the indictment, CVC physicians automatically scheduled annual NSTs for patients without actually seeing them to determine whether the test was actually needed in violation of Medicare medical necessity rules and a CMS Local Coverage Determination banning use of NSTs as a screening procedure. On Dec. 5, the physicians agreed to settle the case for $1.2 million rather than risk a trial.

NST Bundling: The NYC Case
Coding of NSTs may also raise FCA red flags. There are three possible CPT codes for billing the imaging part of the test:

• Code 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.

NST coding irregularities were at the center of one of the largest diagnostic fraud cases of 2017—the $50+ million scam allegedly perpetrated by a cardiologist, neurologist and four others associated with a New York City medical practice this spring. Among other things, the defendants have been charged with NST coding abuses, specifically listing only one code for “Nuclear Studies” in the practice’s superbill: 78452. As a result, 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: For clinical labs, none of this is new. Routine ordering, medical necessity and bundling of costly tests have been fundamental compliance challenges to labs for decades. However, now these same enforcement principles are being applied with increasing regularity to target not just NSTs but other elaborate diagnostic procedures.