By Karie Rego

Ever since the Redding Medical Center government investigation found inappropriate percutanteous coronary interventions (PCI), the medically necessity of PCI has been a highly debated topic. This past year, there have been two other similar cases involving providers in Maryland and Pennsylvania. In Maryland, the state even considered adopting it’s own quality guidelines. This is a high risk area for providers an can impact both reputation and reimbursement.

It’s important for providers to know the latest developments. CMS has publicly stated that it believes that 50% of PCI interventions are medically unnecessary. The 50% number was cited in the Redding court filings. Generally at issue is the "elective" and not emergent PCI. More recently, data generated by non-governmental entities like the Dartmouth Health Atlas has been used to compare PCI in Redding to other California areas showing a dramatic decrease in PCI in the Redding area lower than the state average.

Providers should be aware that this data is used to argue that the new Redding PCI levels are the correct levels even though clearly the government investigation caused several interventionists to stop practicing and may have caused a general chill on PCI in the area.

The professional societies have stepped up their activity as well. An American College of Cardiology (ACC) Task Force published extensive Appropriateness Guidelines in 2009. The guidelines basically assist in PCI decision-making by grouping cases into appropriate, inappropriate and uncertain categories. Last month, an ACC review of 500,000 cases around the country from July 2008 to June 2010 found 11.6% of cases were inappropriate, 38% were uncertain and 50.4% were appropriate.

These ACC Guidelines and studies necessitate provider action. The government will use the ACC findings to support its assertions that only 50% of PCI is medically necessary. Providers should put measures in place to show that uncertain cases are medically necessary. The first step would be to use the ACC guidelines to weed out the inappropriate cases by conducting a focused audit under attorney-client privilege. Making a repayment of these cases will be very effective in preventing further scrutiny, bringing problematic physicians in line and reducing the likelihood of staff whistleblowers.

For the uncertain cases, providers should adopt preventive measures to document: (1) medical interventions; (2) patient consent to PCI as the preferred option; and (3) improved physician documentation and even potential incentives for meeting quality goals.

If providers act proactively in this important service area they can protect both their reputation and reimbursement. 

For more information, please contact Karie Rego at krego@sheppardmullin.com or (415) 774-3187.