Watch List? Comparative Billing Reports Alert Cardiologists to CMS Scrutiny

In May 2015, approximately 2,500 cardiologists and internists received reports from the Centers for Medicare & Medicaid Services (CMS) that some found alarming. The reports detailed transthoracic echocardiography (TTE) use by the physicians and their centers in 2014. CMS said the reports were intended to be educational, but questions remain about Medicare’s ultimate goal and whether last year's scrutiny will lead to audits.

Panic mode

Comparative billing reports (CBRs) are not new. Since 2010, CBRs have been issued across a variety of medical specialties and services. Last year, however, marked the first time that TTE was a focus of this kind of Medicare analysis. One reason the reports caused confusion was because they arrived not with Medicare’s seal, but that of CMS contractor eGlobalTech.

Despite reassurances from Medicare, there were reasons to be concerned, according to Denise Garris, a principal at The Korris Group, a healthcare consulting firm that represents the American Society of Echocardiography (ASE). Some of the cardiologists assumed they were being audited, while others worried about why CMS had hired a third-party contractor to study TTE utilization.

“Is CMS looking for outliers to do further studies on or to look more closely at?” asks Michael Main, MD, a cardiologist at St. Luke’s Mid America Heart Institute in Kansas City, Mo. “I think that’s a very real concern.” Main didn’t receive a CBR but, because of his role on ASE’s advocacy committee, was contacted by concerned physicians.

“CMS never does anything without a purpose,” says Garris. That’s especially true, she says, when it involves hiring a contractor to review Medicare-covered services.

Looking for patterns

In the past two years, CMS issued nearly 134,000 individual CBRs to healthcare providers in 20 different areas. The last time CBRs were issued for cardiology services was in 2012.

At press time, a total of seven CBRs had already been or were slated to be released in 2016. One of them revisits electrodiagnostic testing, which was the focus of two previous CBRs, in 2011 and again in 2014. The fact that CMS is taking a third look at electrodiagnostic testing, although at different codes, is a reminder that CMS can at any time return to services of concern.

The purpose of CBRs is to “provide comparative data on how individual health care provider’s billing and payment patterns for certain topics compare to their peers,” CMS spokesperson Tony Salters wrote in an email exchange with Cardiovascular Business. Other aims are to help physicians better understand Medicare billing rules, to encourage providers to check their records against CMS’s files and to consider whether they are appropriately addressing Medicare guidelines, according to Salters.

CBRs tend to be sent when CMS or its contractors spot billing practices “identified as having different, but not necessarily incorrect, billing patterns when compared to their peers,” Salters wrote. Red flags may include higher-than-average reimbursement from Medicare and concerns about overuse and practice variation.

Salters says TTE “was chosen because the Office of Inspector General has identified potentially inappropriate billing and overutilization for [TTE] services,” and because “beneficiaries in high-use counties received twice as many ultrasound services in comparison to the rest of the country. In addition, the ratio of ultrasound providers to beneficiaries in those counties was three times more than the rest of the nation” (

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Questioning the methodology

ASE’s analysts cite concerns raised by their constituents about the nature of the data provided in the CBRs. Garris points to cardiology-wide efforts to reduce unnecessary testing, including development of appropriate use criteria and participation in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. More important, according to Garris, are the codes CMS used to generate the CBRs. Not only do those codes do a poor job of defining high-volume centers from individual cardiologists, she says, but CMS also failed to factor in that the physicians whose names are on the claims are not always the providers who ordered the tests.

“It might be their primary care provider who is referring a patient for an echo,” Garris explains. Holding cardiologists accountable for tests they did not order has been “an age-old issue across all of cardiology with regards to nuclear, SPECT imaging, CT, MRI, anything of that nature—making sure that the appropriate test is ordered on the appropriate patient.”

ASE also raised concerns about how to assess medical necessity from afar. “We just think that there appear to be a lot of flaws in the methodology,” Main says. “We’re not sure that there’s really any educational point to be made [with the CBRs], particularly if you don’t risk-adjust or adjust for the number of patients that a particular individual or practice is seeing. [The reports] just don’t really have any value.”

One study found that the field might need to take a look at TTE use but that the focus should be on whether it is being underutilized considering its benefits. Physicians from Mount Sinai Medical Center in New York City analyzed data from National Inpatient Sample (NIS) from 2001 through 2011. They found that, despite favorable outcomes, including decreased relative risk of mortality, shorter lengths of stay and reduced hospital charges, TTE was performed in only 7.4 percent of about 2.9 million national diagnoses for acute myocardial infarction, congestive heart failure, dysrhythmia, acute cerebrovascular disease and sepsis (J Am Coll Cardiol 2014;63 [12_S]).

Preparing for anything, or nothing

Soon after the TTE reports were distributed, ASE asked CMS to clarify its intentions with the reports as well as its longer-term plans. CMS and eGlobalTech hosted  a webinar stressing that CBRs are not themselves audits, that they noted trends and did not examine medical necessity (

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Regardless of what CMS said about CBRs being educational tools, audits are possible, says Amy K. Fehn, Esq., a health law attorney from Troy, Mich., who has worked with medical providers who were audited after receiving a CBR. The CBR indicates the service is on CMS’s radar as potentially overpaid. Being noted as a possible outlier puts a provider into a narrower field of focus.

While the TTE reports may signal CMS is “focusing on regions of concern rather than specific providers,” receiving a CBR should nudge physicians and practices to review their processes and documentation, says Fehn. It’s not unprecedented for CMS to audit physicians who are “just involved in reading or performing a test even if it was ordered by someone else,” she says. In that scenario, the physician being audited will need access to all of the documentation that reports medical necessity, including patient notes and supporting information, she says. “Make sure [you] have a process in place [for accessing documents when tests are performed] or have a good relationship with [referring providers, so you] can get the information.”

In the year since the TTE reports were issued, ASE has distributed more coding guidance and is asking CMS to make both the reports it distributes and its intentions clearer, according to Garris. ASE also is planning to reevaluate whether physician marketing and practice guidelines for the family of echocardiography codes should be reexamined. At least one of the codes that the CBR focused on (93306) is “on the [CMS] list of potentially misvalued services,” she says. 

No matter what, Garris doesn’t want cardiologists to dismiss the reports just because a year has gone by without further communication from CMS or its contractors. “Don’t let this drop,” she warns. “I freely admit I wear the paranoid hat. I’m wondering, ‘What [is CMS] trying to tee this up for?’”