title: The diversion of outpatient echocardiography from private offices to higher cost hospital facilities: an unanticipated effect of code bundling.
abstract: OBJECTIVE
  In 2009, the add-on codes for spectral Doppler and color flow Doppler echocardiography were bundled into the code for primary transthoracic echocardiography. The relative value units for the new single code were substantially lower than the previous sum for the 3 codes. The purpose of this study was to see how this affected the distribution of outpatient echocardiographic studies between cardiology offices and hospital outpatient departments (HOPDs).
  
  
  METHODS
  The 2005 to 2011 Medicare databases were used. All echocardiography Current Procedural Terminology codes were selected. Specialty codes identified those done by cardiologists (who do most echocardiographic studies). Place-of-service codes identified those done in offices and HOPDs. Procedure volumes and utilization rates per 1,000 were determined each year before and after bundling occurred in 2009.
  
  
  RESULTS
  Cardiologists' office echocardiography utilization rate rose from 219.5 per 1,000 in 2005 to 257.1 in 2008 (+17%), then dropped to 100.0 in 2009 (-61%) because of bundling. Their HOPD echocardiography rate rose from 72.2 in 2005 to 76.5 in 2008 (+6%), then dropped to 35.0 in 2009 (-54%). From 2009 to 2011, cardiologists' office echocardiography rate dropped again from 100.0 to 88.8 (-11%), while their HOPD rate increased from 35.0 to 46.1 (+32%).
  
  
  CONCLUSIONS
  Echocardiography code bundling produced the expected sharp drop in outpatient claims from cardiologists in 2009. But after bundling, office echocardiography rates continued to drop, while HOPD rates increased. It seems that in this instance, code bundling led to the closure of many cardiology offices and a resultant shift of echocardiography from that lower cost setting to the higher cost HOPD setting.
authors: Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, Philadelphia, Pennsylvania; HealthHelp, Inc, Houston, Texas. Electronic address: david.levin@jeffersonhospital.org.
authors: David C
authors: DC
authors: Levin
authors: Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, Philadelphia, Pennsylvania.
authors: Laurence
authors: L
authors: Parker
authors: Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, Philadelphia, Pennsylvania.
authors: Ethan J
authors: EJ
authors: Halpern
authors: Center for Research on Utilization of Imaging Services, Department of Radiology, Thomas Jefferson University Hospital and Jefferson Medical College, Philadelphia, Pennsylvania.
authors: Vijay M
authors: VM
authors: Rao
mesh_terms: D000553:Ambulatory Care / Q000191:economics*; D059019:Clinical Coding; D015150:Echocardiography, Doppler / Q000191:economics*; D006801:Humans; D006278:Medicare / Q000191:economics; D064872:Patient Care Bundles / Q000191:economics*; D010824:Physicians' Offices / Q000191:economics; D010818:Practice Patterns, Physicians' / Q000191:economics; D011872:Radiology Department, Hospital / Q000191:economics*; D014481:United States
keywords: Medical economics; cardiology and cardiologists; code bundling; echocardiography; radiology and radiologists; socioeconomic issues