Coronary CTA Reimbursement

Numerous clinical guidelines recommend coronary computed tomography angiography (CTA) as a first-line diagnostic test for screening patients suspected of coronary artery disease because it can improve patient outcomes as compared to other diagnostic tests [1]. Although coronary CTA has demonstrated value in clinical practice, its adoption and utilization in the United States have historically been challenged by the rate at which it is reimbursed through Centers for Medicare and Medicaid Services (CMS).

In this post, we examine the current challenges for coronary CTA reimbursement, how these challenges may impact care delivery, and the steps medical imagers can take to help improve reimbursement for coronary CTA moving forward.

How are healthcare providers reimbursed for coronary CTA?

Coronary CTA CPT Codes

Reimbursement describes the payment that is given to a physician or healthcare system for providing services to a patient. To get reimbursed through Medicare, providers must appropriately code the services they have provided using Current Procedural Terminology (CPT) codes, as well as International Classification of Disease (ICD-10) codes.

Current Procedural Terminology codes are five-digit numeric codes developed and maintained by the American Medical Association (AMA) that are used to help providers report procedures, services, devices, and drugs in a standardized manner. These codes are reviewed and updated by the AMA on an annual basis. Current Procedural Terminology codes are grouped into the following three categories:

Category I CPT Codes are the most used set of codes within CPT, describing most of the procedures performed by providers in inpatient and outpatient settings.
Category II CPT Codes are supplementary tracking codes used for performance measures to help collect information about the quality of care.
Category III CPT Codes are temporary codes that are awarded to emerging technologies, services, and procedures

There are currently four Category 1 CPT Codes used to report cardiac CT procedures, which include:

CPT Code 75571: Computed tomography of the heart without contrast, with a quantitative evaluation of coronary calcium
CPT Code 75572: Computed tomography of the heart with contrast for the evaluation of cardiac structure and morphology
CPT Code 75573: Computed tomography of the heart with contrast for the evaluation of the cardiac structure and morphology in the setting of congenital heart disease
CPT Code 75574: Coronary CTA of the coronary arteries and bypass grafts with contrast, including 3D image postprocessing

How does CMS calculate reimbursement rates?

To calculate Medicare Fee Schedule Rates, the Medicare Physician Fee Schedule uses a resource-based relative value system that assigns a relative value to each CPT code. Dr. Dustin Thomas, Society for Cardiovascular Computed Tomography (SCCT) Advocacy Committee Chair, described the process CMS uses to calculate reimbursement rates in an SCCT Webinar on Coronary CTA Reimbursement.

According to Dr. Thomas, the first thing CMS takes into consideration is cost. Each hospital files a cost report annually with CMS that breaks down operational costs on a departmental basis. Centers for Medicare and Medicaid Services then uses a chargemaster—a comprehensive list of charges for any given procedure—in combination with a cost report to determine a Cost-to-Charge Ratio. They then multiply the billing charge for a specific CPT code by the Cost-to-Charge Ratio to generate the Estimated Cost of a procedure. Dr. Thomas then explained that the Estimated Cost calculated by CMS is used to determine a geometric mean reimbursement rate which allows CMS to group CPT codes based on the similarity of procedure and cost. Finally, the Geometric Mean reimbursement rate is used to place CPT codes into Ambulatory Payment Classification (APC) where procedures are grouped based on similarity of procedure and similarity in geometric mean cost.

A global procedure contains both a Professional Component as well as a Technical Component. The technical component of a procedure includes all necessary equipment, supplies, personnel, and costs related to performing an exam. In contrast, the professional component—which is identified by adding modifier 26 to the procedure code—includes the supervision, interpretation, or written report affiliated with a procedure.

According to the Medicare Physician Fee Schedule Search Tool, the global price of a coronary CTA procedure without modifiers in 2021 is $295.20 [2]. This total cost includes both the professional and technical components of performing a coronary CTA exam. The technical component of the procedure is reimbursed by CMS at $178.30.

Challenges for Coronary CTA Reimbursement

Members of professional societies including the SCCT have stated that the current methodologies used by CMS underestimate the costs for coronary CTA and impact the rate at which it is reimbursed. As described by Dr. Juan Batlle during the SCCT Virtual presentation “What I Wish I had Known in Cardiac CT: Clinical Reporting and Understanding Finance,” CMS has repeatedly confirmed cuts to the technical component of reimbursement for cardiac CT, resulting in over a 33% reduction for coronary CTA since 2017.

Several of the existing challenges facing coronary CTA reimbursement in the U.S. include the underreporting of costs by healthcare providers and the inappropriately low charges on CT chargemasters across the country. According to Dr. Thomas, there are centers across the U.S. that charge as little as one dollar for calcium scoring, and as little as 28 dollars for coronary CTA. Because these charges are significantly lower than the actual costs of the test, they dramatically lower the rate of reimbursement.

The technical component of coronary CTA is reimbursed by CMS at a rate far lower than that of other cardiovascular imaging diagnostic tests. Dr. Ron Blankstein, Associate Director of the Cardiovascular Imaging Program at Brigham and Women’s Hospital described the challenges with the CMS payment rate for coronary CTA in the SCCT Virtual session, “Next Steps in Advocacy for CCT.” According to Dr. Blankstein, cardiac CT procedures—which include CPT codes 75572, 75573, and 75574—are assigned to APC 5571: Level 1 Imaging with Contrast based on the data that hospitals submit to CMS. The geometric mean costs for the tests placed in APC 5571 range between $157 and $196 according to the OPPS Final Rule, and includes procedures such as contrast-enhanced thoracic CT (CECT) and hand x-ray with contrast. These tests take a fraction of the time to perform and are less labor-intensive than coronary CTA procedures, as stated by Dr. Blankstein.

As a result, the technical component of Single Photon Emission Computed Tomography (SPECT) is reimbursed at a rate roughly six times higher than the technical component for coronary CTA. This discrepancy in reimbursement for the technical component of coronary CTA procedures may incentivize providers to utilize diagnostic tests that will result in better pay, despite current recommendations that advocate for the use of coronary CTA as a first-line diagnostic test in patients suspected of coronary artery disease.

Comparing Reimbursement for Coronary CTA to Contrast-enhanced Thoracic CT

This was further described in a recent study published in the Journal of Cardiovascular Computed Tomography that investigated the direct costs of coronary CTA relative to CECT. In this paper, Zimmerman et al. evaluated the actual costs of the technical component for both coronary CTA and CECT in June 2020 as the TC for each of these exams are equivalent under the Outpatient Prospective Payment System (OPPS).

To examine the direct cost of performing the technical components of coronary CTA and CECT in an outpatient setting, the researchers analyzed coronary CTA procedures billed as CPT code 75574 and CECT billed as CPT code 71260. The study included 28 coronary CTA and 26 CECT procedures performed at seven geographically diverse medical centers across the United States during February 2020.

According to the study results, performing a coronary CTA exam required significantly more time than performing a CECT exam, taking an average of 107 minutes to complete a coronary CTA exam compared to an average of 30 minutes to complete a CECT exam. According to Michael E. Zimmerman et al., the greater time to perform a coronary CTA was accompanied by greater labor efforts. As a result, the direct technical costs for outpatient coronary CTA and CECT across the health systems found a 3.4 times greater cost associated with coronary CTA as compared to CECT.

Coronary CTA Advocacy: What is Being Done in 2021?

During the SCCT 2021 Virtual Meeting, Dr. Thomas summarized SCCT efforts advocating for improved coronary CTA reimbursement in collaboration with the American College of Cardiology (ACC), American College of Radiology (ACR), and Radiological Society of North America (RSNA).

The SCCT has made significant progress over the past year in moving the needle toward improved reimbursement for coronary CTA. In 2021 alone, various SCCT stakeholders have engaged with CMS, meeting virtually with members of the Department of Outpatient Care (DOC) in February 2021, and members of the Department of Cost Reporting (DCR) in March 2021. Despite these efforts, Dr. Thomas summarized those two meetings during SCCT Virtual, stating that the challenges with reimbursement for coronary CTA were not addressed in those two meetings.

As a result, SCCT is spearheading a new strategy to improve coronary CTA reimbursement, taking the issue to Capitol Hill. To support the efforts, SCCT has commissioned Capitol Counsel, a government relations firm that provides political analysis, strategic advice, and advocacy services, to help SCCT connect with strategic partners, grow constituency of stakeholders, and engage and gain direct access to congressional leaders. The SCCT has also conducted an exploratory campaign to investigate the logistics of starting a Political Action Committee (PAC) through the SCCT as well. In the coming year, SCCT stakeholders will meet with congressional leaders to advocate for the need for increased reimbursement for cardiac CT, continue engaging with CMS regarding the current flaws in the existing reimbursement methodologies and collaborate with the RVS Update Committee on revisions to existing cardiac CT codes. Each of these efforts intends to improve payment for cardiac CT to support the widespread adoption and utilization of coronary CTA as a first-line diagnostic test in the United States.

How to Help Improve Reimbursement for Coronary CTA

Over the past year, the SCCT, ACR, and ACC have taken monumental steps to help encourage improved reimbursement for coronary CTA. Moving forward, additional advocacy from clinicians and industry personnel will be essential to moving the needle. Medical imagers can help to support progress in coronary CTA reimbursement by taking the following steps:

Promote Education & Awareness on Coronary CTA Guidelines and Reimbursement: The SCCT Advocacy committee continuously publishes educational resources to promote transparency, understanding, and awareness on topics related to reimbursement for cardiac CT. Stay up to date on the current coronary CTA guidelines and recommendations as well as SCCT’s reimbursement webinars and share them with colleagues to educate other clinicians.
Ensure Standardization in Reporting: Capturing accurate data within your institution is essential to improving reimbursement rates for coronary CTA. Medical imagers should ensure the standardization of protocols, and check that reporting templates align with current guidelines from professional societies such as the SCCT. Refer to the SCCT Guidelines for the Interpretation and Reporting of Coronary CT Angiography: A Report of the Society for Cardiovascular Computed Tomography Guidelines Committee which provides an educational tool for clinicians to develop standards of practice for coronary CTA for additional information.
Support Professional Societies including SCCT, ACC, and ACR: Professional societies are committed to continuing advocacy efforts for coronary CTA reimbursement. Participate in SCCT Advocacy to help move the needle in coronary CTA reimbursement.

References

[1] Michael P., Lesser, J.R., Biga, C., Blankstein, R., Kramer, C.M., Min, J.K., Noack, P.S., Farrow, C., Hoffman, U., Murillo, J., Nieman, K., Shaw, L.J. (2020). Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable Coronary Artery Disease. Journal of the American College of Cardiology. 76(11), 1358-1362.

[2] Physician Fee Search Tool; 2021. Accessed July 1, 2021 at https://www. cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.

[3] Zimmerman ME, Batlle JC, Biga C, Blankstein R, Ghoshhajra BB, Rabbat MG, Wesbey GE, Rubin GD. The direct costs of coronary CT angiography relative to contrast-enhanced thoracic CT: Time-driven activity-based costing. J Cardiovasc Comput Tomogr. 2021 Jun . doi:10.1016/j.jcct.2021.06.002. PMID: 34210627.

Editor’s Note: An earlier version of this post was published in November 2020 and has been updated for accuracy and comprehensiveness.

Coronary CTA Reimbursement: Opportunities & Challenges