Written By: CJ Wolf, MD
This article presents educational information related to compliant documentation, coding and billing to avoid fraud, waste and abuse in our healthcare system. Dr. Wolf makes his point by presenting a qui tam case related to vascular diagnostic testing.
Medical coding is a critical aspect of accurate reimbursement for a variety of medical services. Many healthcare compliance enforcement actions, especially those brought under the Federal False Claims Act (FCA), stem from allegations of inaccurate coding.
Healthcare compliance professionals can learn a great deal from diving deep into the details of various enforcement actions. As it relates to medical coding, some enforcement actions teach compliance and coding professionals a great deal of how inaccurate coding can lead to significant investigations and multi-million-dollar settlements.
The details behind a recent $37 million settlement between the U.S. government and a medical device company, along with their former distributor, inform coders and compliance professionals about the risks of inaccurate coding related to a common medical condition known as peripheral arterial disease (PAD)1.
PAD in the lower extremities is the result of narrowing or blockage of the arteries carrying blood with oxygen to the legs. A common symptom for patients with PAD is leg pain when walking. This type of pain is frequently referred to as claudication. Physicians use their clinical knowledge, experience and certain tests to diagnosis PAD and its varying degrees of severity.
One of the most common diagnostic tests utilized by physicians to evaluate PAD is the ankle brachial index (ABI). The test can help estimate the severity of the blockage, which is important when planning treatment and management options. Medicare has coverage policies and requirements for tests that can measure blood circulation in situations such as PAD. The critical policy that played a major role in this multi-million-dollar settlement is Medicare’s National Coverage Determination (NCD) 20.14 on plethysmography. Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part.
In addition, the definitions of certain Current Procedural Terminology (CPT®) codes, 93922, 92923, or 93924 must be accurately met to submit these codes on claims to Medicare for reimbursement of these diagnostic tests. The medical codes require that a provider conduct an ABI test plus certain additional testing. In addition, Medicare does not cover noninvasive vascular tests that use photoelectric plethysmography, also known as photoplethysmography (PPG), which uses a light sensor to detect changes in blood volume.
For example, the Medicare NCD classifies the types of technology used for the testing that is covered compared to those not covered. The covered and non-covered procedures from the NCD are listed below:
Covered
- Segmental Plethysmography
- Electrical Impedance Plethysmography
- Ultrasonic Measurement of Blood Flow (Doppler)
- Oculoplethysmography
- Strain Gauge Plethysmography
Non-covered (Medicare considers these experimental)
- Inductance Plethysmography
- Capacitance Plethysmography
- Mechanical Oscillometry
- Photoelectric Plethysmography
Two experts in vascular diagnostic testing filed a qui tam, or whistleblower, lawsuit under the False Claims Act. They alleged the companies were marketing their devices to providers, such as physicians, telling them their testing device could be reimbursed by Medicare even though the procedure used is PPG, which is a non-covered classification as described in Medicare’s NCD. The government intervened in the case and joined in alleging that the medical codes submitted on claims to Medicare were inaccurate, thus the companies caused providers to submit false claims.
According to the legal complaint filed with the courts, the whistleblowers stated that the device manufacturer and their distributor promoted use of their PPG devices as easier, quicker, and less expensive than the use of Doppler technology for diagnosing PAD. They also claimed the companies said Medicare (and other government payers) pay out the same amount for any service that fits within a specific CPT code, irrespective of the actual cost to a medical provider to provide the service. Medical providers are consequently incentivized to perform the most inexpensive and least time-consuming services that qualify for a specific CPT code. Because the company claimed these PPG products are much less expensive and faster than the traditional diagnostic tests the devices can "diagnose" PAD within as little as five minutes, while traditional diagnostic tests take approximately 30-45 minutes.
The legal complaint also included materials about how the companies marketed the devices to providers.
The whistleblowers claimed:
- The companies marketed one of their devices as a "new reimbursable office diagnostic test you can perform quickly and easily with no capital equipment purchase and no specialized personnel."
- A physician gave a presentation at the New Cardiovascular Horizons (NCVH) conference and promoted the device as a method to help "increase your daily practice revenue." The presentation addresses the CPT codes that can purportedly be used to bill Medicare for services using the device and lists CPT codes 93922 and 93923.
Lessons Compliance Professionals Can Learn
Compliance professionals working for hospitals or physicians can learn a great deal from these details, such as:
- First, compliance professionals should ensure the accuracy of any coding and reimbursement advice coming from device and/or pharmaceutical manufacturers.
- Second, diligently review and follow Medicare and Medicaid coverage policies.
- Third, go beyond just reading a medical code’s definition. Review enforcement settlements, audits, and authoritative references for the proper and intended use of medical codes.
This is just one of many enforcement actions that healthcare compliance professionals should be conversant about if they perform services for the common condition of PAD.
About the Author
CJ Wolf, MD, CPC, CPB, COC, AAPC Approved Instructor, is a highly regarded healthcare professional with more than 25 years of experience in revenue cycle management, practice management, compliance, coding, billing, auditing, and client services. He is a nationally recognized compliance thought leader who has published numerous articles and resources and has been featured at national conferences and events. He is a subject matter expert with Healthicity, a leading provider of compliance and auditing software solutions at https://www.healthicity.com
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