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Inaccurate Coding of Non-Invasive Tests May Call Into Question Clinical and Policy Recommendations Based on Administrative Databases
Michael R. Go, M.D., Brent Veerman, Loren Masterson, M.D., Bhagwan Satiani, M.D., M.B.A..
The Ohio State University, Columbus, OH, USA.

OBJECTIVES: To curb increasing volumes of diagnostic imaging and costs to Medicare, reimbursement for carotid duplex ultrasound (CDU) is dependent on appropriate indications as documented by International Classification of Diseases (ICD) codes entered by ordering physicians. In our vascular laboratory, we have noted an increased need to discuss incorrect or inappropriate ICD codes with ordering physicians. We therefore sought to analyze the accuracy of ICD coding by identifying the rate of positive CDU for each indication. We hypothesized that symptomatic indications would yield a higher rate of positive CDU than asymptomatic or non-specific indications.
METHODS: We reviewed all CDU done on Medicare out-patients in 2011 at our institution. ICD codes and CDU findings categorized as positive (> 50% stenosis) or negative (< 50% stenosis) were recorded. Each individual ICD code as well as group 1 (asymptomatic), group 2 (non-hemispheric symptoms), group 3 (hemispheric symptoms), group 4 (preoperative cardiovascular exam), and group 5 (non-specific) ICD codes were analyzed for correlation with CDU results.
RESULTS: 994 Medicare patients had 74 primary ICD codes listed as indications for CDU. The 13 highest frequency ICD codes were analyzed; five codes were associated with positive CDU (Table). Patients in group 1 (asymptomatic) were significantly more likely to have a positive CDU compared to each of the other groups and to all other groups combined (P < .00001). Group 2 (non-hemispheric symptoms) patients were also more likely to have a positive CDU compared to all other groups combined (P < .0073).
CONCLUSIONS: Both asymptomatic and non-hemispheric indications by ICD codes yielded a higher rate of positive CDU than symptomatic indications. While other explanations may also be possible, these findings are inconsistent with clinical experience and historical data. We suggest that inaccurate coding, either inadvertent or to obtain desired testing, may play a role. Erroneous or ambiguous ICD coding may degrade the testing efficiency of CDU. Clinical studies and policy recommendations on reimbursement based on administrative databases must be viewed with caution unless validated with audits by clinical personnel.

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