Passman M A, Guzman R J, Pierce R, Naslund T C
Division of Vascular Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2735, USA.
J Vasc Surg. 2001 Nov;34(5):846-53. doi: 10.1067/mva.2001.119229.
The purpose of this study was to evaluate the impact of Medicare coverage limitations and claim denials on noninvasive vascular diagnostic testing.
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.
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."
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.
本研究旨在评估医疗保险覆盖范围限制和索赔拒付对非侵入性血管诊断检测的影响。
根据颈动脉双功超声扫描、静脉双功超声扫描和下肢动脉多普勒扫描的现行程序术语代码，从医院计费数据库中识别出1999年1月1日至1999年12月31日期间所有医疗保险报销的非侵入性血管诊断研究申请。审查医疗保险拒付这些检测费用的原因，并进行成本分析。
在这1年期间，对医疗保险患者进行了1096项非侵入性血管诊断研究。在这1096项检测中，176项（16.1%）被医疗保险拒付（408项颈动脉双功超声扫描中的19.6%，345项静脉双功超声扫描中的16.8%，343项下肢动脉多普勒扫描中的11.1%）。在被医疗保险拒付的非侵入性血管检测中，72.5%的颈动脉双功超声扫描、32.8%的静脉双功超声扫描和78.9%的下肢动脉多普勒扫描结果异常。总体而言，所有最初被拒付的索赔（N = 176）中有88.1%在重新提交后最终获得了医疗保险的报销，其中基于“医疗必要性”合规规则被拒付的118项索赔中有77.1%获得了报销。
由于覆盖范围限制，如果未识别被拒付的索赔，医疗保险对非侵入性血管诊断检测的拒付可能导致医生和医院的技术费用潜在无法得到补偿。进行这些检测的血管实验室需要审查是否符合医疗保险指南。在为适当开具的非侵入性血管诊断研究获得报销方面，可能需要在提供者和医疗保险承保方层面都做出改进。
