In order to meet Medicare coverage requirements, all vascular laboratory studies must (1) have a valid, recorded medical indication; (2) be ordered by a licensed independent provider; (3) have archived retrievable test data; and (4) include a physician’s professional interpretation. Each of these will be examined in more detail.

What constitutes a valid medical indication can be a frustrating issue for vascular lab managers, because the clinical indication as listed on the requisition or physician’s order oftentimes determines whether a service is covered, meaning paid, by the patient’s insurance carrier. A clinical indication that the ordering provider believes is totally appropriate and may not be considered valid by the carrier. For example, a primary care provider orders a carotid duplex on a 60-year-old lifelong smoker who is asymptomatic. The PCP is concerned, not only because of the obvious risk factors, but in this particular case, two of the patient’s brothers and three of his sisters have all suffered strokes. However, the patient’s insurance carrier may consider this a non-covered “screening” exam if the patient has no lateralizing neurologic symptoms. If the study demonstrates significant carotid stenosis, then the diagnosis can be based on the test findings, and the exam will likely be covered. In the less likely situation that the patient has no significant carotid plaque, then the lab manager is faced with a dilemma. The insurance carrier sticks with “screening” and likely will refuse to pay. Thus, agreeing to perform this exam is a bet by the lab manager that the patient will have substantial carotid plaque. If none is found, then the lab may end up performing the study for no reimbursement. Refusing up-front to perform the exam antagonizes the patient and irritates the ordering provider. On the other hand, performing the exam with the possibility of no payment can only be done a limited number of times, if the lab is to remain fiscally viable.

From the Medicare perspective, the correct approach in this setting is for the lab to provide the patient with an “Advanced Beneficiary Notice ” or “ABN,” a document that explains to the patient that he or she is about to undergo a test that the Carrier believes is not medically indicated and, therefore, will not be covered by insurance. This ABN approach, while meeting payer requirements, may oftentimes engender ill will. The patient may ask why the PCP is ordering an unindicated test. If not exceptionally clear and tactful, the vascular lab manager’s response may confuse the patient even further, potentially delaying the schedule or resulting in patient refusal to undergo the exam. The best way to avoid this annoying and oftentimes costly issue is to educate one’s ordering providers regarding the relevant national and local coverage decisions. For the Medicare program, an updated list of coverage decisions may be found at https://​www.​cms.​gov/​medicare-coverage-database/​indexes/​national-and-local-indexes.​aspx .

The value of archived retrievable vascular lab data is obvious. Every vascular study should compare current test results to those of prior exams. In order to do so efficiently, the lab must have ready access to archived data. Most vascular labs now use digital Picture Archive and Communication Systems (PACS) . While there is no additional reimbursement for implementing a PACS system, the addition of instant retrieval ability not only streamlines one’s ability to compare previous studies to current, but a PACS system also serves to protect the vascular lab in case of a post-payment audit. Medicare’s initiative to eliminate overpayments remains in high gear. A solid set of records demonstrating quality data, appropriate clinical indications, and accurate coding and billing will be of great assistance should Medicare decide your lab merits a post-payment evaluation.