The Shifting Landscape of Cardiac CT Angiography Reimbursement

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Many imaging providers have been wishing for changes in reimbursement policies for cardiac CT angiography (CCTA) for some time. Changes are about to be made, but those wishes may not be granted. In December 2007, CMS proposed major restrictions on coverage for CCTA that could take effect as early as March 2008. The conclusions that CMS discussed in the proposed coverage determination would, if implemented, have a profoundly negative impact on Medicare beneficiaries by limiting needed access for clinically appropriate indications for using this technology (see sidebar).

Whether or not the new CMS National Coverage Determination (NCD) for CCTA is implemented, other reimbursement controversies have the attention of providers. Prominent among these is the issue that providers face of how to report appropriately and accurately on the data obtained during CCTA studies. These collaborative or supplemental readings often constitute a gray area for payors, so imaging providers may need to adopt a team approach. It is important to note that these are not separately billable services. Using a team approach provides an accurate and timely interpretation of the data obtained and provides our patients the highest quality care.

There are several business models that are in use. All models need to ensure that all providers are appropriately trained and credentialed to provide the interpretation of these studies. Let’s discuss some of these models. Using a competitive reimbursement model, the referring physician who is ordering the test, selects the study's reader, who bills for the full interpretation; this is especially likely if neither specialty concedes primary reader status to the other. Some feel if the selected reader is a cardiologist, the noncardiac portion of the study may still require interpretation; conversely some wonder if a radiologist can completely interpret the coronary tree.

CCTA Coverage Update

A surprise proposal issued by CMS on December 13, 2007, would radically change Medicare reimbursement for cardiac CT angiography (CCTA). If adopted, it could also set a precedent that would create major obstacles for the coverage of future imaging technologies and applications.

The proposal would use a restrictive National Coverage Determination (NCD) to replace the Local Coverage Determinations that now cover CCTA throughout the United States. Under the NCD, Medicare reimbursement would be disallowed for all but two CCTA indications. For those two, reimbursement would be permitted only for patients enrolled in CMS-approved controlled clinical trials. In addition, the trials would be required to determine whether patient outcomes were improved by CCTA.

This is the first time that CMS has linked outcomes and imaging in this way, and the influence of this requirement could be detrimental to imaging as a whole. Because outcomes are highly dependent on diagnosis, treatment, and patients' behavior, their connection to prior imaging procedures is indirect and difficult to assess. Even the best possible imaging could lead to poor outcomes, if followed by inadequate treatment and/or insufficient patient compliance. Unless huge trials can be designed to control for all the variables that come between imaging and outcomes, it may simply be impossible to connect the two, for CCTA or any other kind of imaging.

The two groups covered within trials under the NCD proposal are symptomatic patients with chronic stable angina who are at intermediate risk for coronary-artery disease and symptomatic patients with unstable angina who are at low risk for short-term death and at intermediate risk for coronary-artery disease. Considerable public comment (which was accepted by CMS until January 12, 2008) has focused on this choice of indications, which are not thought to have the highest diagnostic yield for CCTA.

Instead, its high negative predictive value makes CCTA especially valuable for ruling out cardiac origins of chest pain in patients (particularly those in emergency settings) in who heart problems are unsuspected and unlikely. By preventing unnecessary cardiac catheterization, this application of CCTA saves both money and time. This may be the most common use of CCTA, and is probably among the reasons that it is now being performed at more than 2,000 US facilities.

Professional societies have submitted extensive commentaries to CMS, pointing out these problems and adding that much of the recent evidence was not considered