Game of Upcodes: PCI for Stable Angina Slipping Through the Cracks

Outpatient centers appear to have misclassified patients with stable angina as having unstable angina to give them inappropriate percutaneous coronary intervention (PCI), according to a report focused on three U.S. states.

After the release of Appropriate Use Criteria (AUC) for coronary revascularization in 2009, the proportion of outpatient PCIs labeled as acute increased in all three states studied: New York (0.6% in 2010 to 8.3% in 2014), Michigan (2.4% to 6.5%), and Florida (2.4% to 3.8%).

The increases were mostly driven by outpatient PCIs coded for unstable angina, with smaller increases also observed for acute MI, reported Robert Yeh, MD, MSc, of Beth Israel Deaconess Medical and Harvard Medical School, and colleagues.

At the same time, the proportion of inpatient PCIs for unstable angina stayed fairly flat, the group showed in a study published online in JAMA Internal Medicine.

“Our data raise the possibility that physicians increasingly classified patients with stable chest pain as unstable angina in the outpatient setting, or that hospitals shifted coding patterns, potentially owing to external factors including reporting of appropriateness or differences in reimbursement,” Yeh and colleagues wrote.

“PCIs performed for acute MI and unstable angina in an outpatient setting should be infrequent and remain stable over time — a significant increase would suggest potential shifts in diagnostic and/or coding patterns,” they explained.

Yeh’s group studied the Healthcare Cost and Utilization Project state databases, which listed PCIs in both inpatient and outpatient settings in the 2010-2014 period (n=615,649).

During this period after release of the AUC, New York also announced in 2011 that inappropriate PCIs performed for patients insured by Medicaid would no longer be reimbursed in that state.

So it was notable that New York had the biggest shift in outpatient acute PCIs, noted Yeh’s group, suggesting that this policy might have backfired in hiding, rather than eliminating, inappropriate PCIs.

“The rationale for upcoding of unstable angina remains unclear but very concerning.The AUC were intended for internal quality improvement and benchmarking by PCI programs,” according to an invited commentary from Christian McNeely, MD, and David Brown, MD, both of Washington University School of Medicine in St. Louis. “Thus, without public disclosure of the appropriateness of procedures performed by individual hospitals or cardiologists, there is no motive for upcoding to improve the public perception of quality and enhance referrals.”

“Furthermore, since the indication for PCI (stable angina vs unstable angina) does not affect reimbursement, differential payment is unlikely to explain upcoding. A more likely albeit troublesome explanation could be to justify performance of PCI in patients who may not need the procedure,” the pair suggested.

McNeely and Brown said that having stable angina patients go straight to PCI without going through guideline-directed medical therapy is a practice that “at best, damages the credibility of the profession, increases health care spending, violates patient autonomy, puts patients at risk of procedural complications and, at worse, may cross the threshold into criminal activity if used to extract reimbursement for unindicated procedures.”

Going forward, it’s important that cardiologists individually and collectively police themselves before outside forces — the federal government, say — start cracking down, the editorialists urged.