Impact of Medicare denials on noninvasive vascular diagnostic testing.
OBJECTIVE
The purpose of this study was to evaluate the impact of Medicare coverage limitations and claim denials on noninvasive vascular diagnostic testing.


METHODS
All Medicare claims for noninvasive vascular diagnostic studies from January 1, 1999, to December 31, 1999, were identified from the hospital billing database according to Current Procedural Terminology codes for carotid artery duplex ultrasound scan, venous duplex ultrasound scan, and lower-extremity arterial Doppler scan. Reasons for Medicare denial of payment for these tests were reviewed and a cost analysis was performed.


RESULTS
During the 1-year period, there were 1096 noninvasive vascular diagnostic studies performed on Medicare patients. Of these 1096 tests, 176 (16.1%) were denied by Medicare (19.6% of 408 carotid duplex ultrasound scans, 16.8% of 345 venous duplex ultrasound scans, and 11.1% of 343 lower-extremity arterial Doppler scans). Of the noninvasive vascular tests denied by Medicare, an abnormal result was present in 72.5% of carotid duplex ultrasound scans, 32.8% of venous duplex ultrasound scans, and 78.9% of lower-extremity arterial Doppler scans. Overall, 88.1% of all initially denied claims (N = 176) were ultimately reimbursed by Medicare after resubmission, including 77.1% of the 118 claims denied based on compliance rules for "medical necessity."


CONCLUSIONS
Because of coverage limitations, Medicare denials of noninvasive vascular diagnostic tests can lead to potential uncompensated physician and hospital technical fees if denied claims are unrecognized. Vascular laboratories performing these tests need to review compliance with Medicare guidelines. Improvements may need to be made at both the provider and Medicare carrier levels in obtaining reimbursement for appropriately ordered noninvasive vascular diagnostic studies.
Passman
M A
MA
Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2735, USA. marc.passman@surgery.mc.vanderbilt.edu
Guzman
R J
RJ
Pierce
R
R
Naslund
T C
TC
D002339:Carotid Arteries / Q000000981:diagnostic imaging; D017721:Hospital Costs / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000191:economics*; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data*; D019458:Insurance Coverage; D006278:Medicare / Q000706:statistics & numerical data*; D020380:Needs Assessment; D012051:Reimbursement Mechanisms; D013714:Tennessee; D018608:Ultrasonography, Doppler / Q000191:economics*; D018616:Ultrasonography, Doppler, Duplex / Q000191:economics*; D017664:Uncompensated Care / Q000706:statistics & numerical data*; D014652:Vascular Diseases / Q000000981:diagnostic imaging* / Q000191:economics*