While echocardiography code bundling produced an expected sharp drop in outpatient claims from cardiologists in 2009, office echocardiography rates have unexpectedly continued to decline, according to a study published online Dec. 9 in the Journal of the American College of Radiology.

As imaging experienced rapid growth in the previous decade, the Center of Medicaid and Medicare Services (CMS) instilled a series of reimbursement cuts, including code bundling. One of the first examples of this was in echocardiography.

The study’s lead author, David C. Levin, MD, of the Thomas Jefferson University Hospital in Philadelphia, and colleagues wrote of the cuts: “Although CMS intended this change as a cost-saving vehicle, it could have an untoward and possible unanticipated side effect: if the reimbursement cuts were drastic enough, it could lead to the closure of private cardiology offices and the shifting of outpatient echocardiography procedures to hospitals, where costs to Medicare are considerably higher.”

Levin and colleagues studied the utilization trends in outpatient echocardiography before and after the bundling occurred to determine if there was any evidence of a shift from the outpatient procedures to hospitals. Data were gathered from the Medicare Part B Physician/Supplier Summary Master Files for 2005 through 2011. Medicare’s physician specialty codes were used to identity outpatient studies performed in private cardiology offices or hospital outpatient departments (HOPDs).

Results indicated that the utilization rate of echocardiography by cardiologists’ offices increased from 219.4 per 1,000 in 2005 to 257.1 in 2008. The utilization rate then dropped to 100.0 in 2009 due to the code bundling. The HOPD echocardiography rate, on the other hand, rose from 72.2 in 2005 to 76.5 in 2008. Though the rate dropped to 35.0 in 2009, it increased from 2009 to 2011 by 32 percent to 46.1.

“Although radiologists do almost no echocardiography and relatively little MPI compared with cardiologists, code bundling has now taken place in other areas of imaging in which they are heavily involved, such as CT of the abdomen and pelvis,” wrote Levin and colleagues. “It is therefore possible that the apparent shift we have reported here in the cardiology community could happen in radiology as well.”