Coronary computed tomography angiography (CTA) has demonstrated value as a first-line test for diagnosing coronary artery disease in symptomatic patients [1]. However, adoption and utilization of coronary CTA in clinical practice in the USA is challenged by the rate at which it is reimbursed. Centers for Medicare and Medicaid Services (CMS) posted the proposed 2021 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (HOPPS) in August. The proposed payment rule will further reduce reimbursement for coronary CTA, for a total reduction of 33% since 2017.

Reducing reimbursement for coronary CTA will likely impact its utilization in clinical practice over time. In this post, we examine the current challenges for coronary CTA reimbursement, the potential effects it will have on patient care, and what steps medical imagers can take to help improve reimbursement for coronary CTA moving forward.

How are healthcare providers reimbursed for coronary CTA?

Reimbursement describes the payment that is given to a physician or healthcare system for providing services to a patient. The United States reimbursement system uses a set of standardized Current Procedural Terminology (CPT) codes that categorize procedures performed by providers. CPT codes are maintained by the American Medical Association (AMA) and are updated annually.
Category 1 CPT codes are the most used codes and are used to report devices and drugs required for the performance of a procedure. There are currently four Category 1 CPT Codes for reporting coronary CTA, which include:
  • 75571: Coronary CT, without contrast, for the quantitative evaluation of coronary calcium
  • 75572: Coronary CT, with contrast, for the evaluation of cardiac structure and morphology
  • 75573: Coronary CT, with contrast, for the evaluation of cardiac structure and morphology in the setting of congenital heart disease
  • 75574: Coronary CTA, coronary arteries and bypass grafts with contrast

Dr. Dustin Thomas, SCCT Advocacy Committee Chair, explained how CMS calculates reimbursement rates for procedures in the SCCT Webinar on CCTA Reimbursement. According to Dr. Thomas, CMS begins by estimating the cost of procedures based on information submitted to them annually by healthcare providers across the US. The cost reports submitted by healthcare systems includes all operational costs billed by the provider each year. CMS then references “chargemasters”–reports maintained by health systems that lists both CPT codes and charge rates—in combination with cost reports to determine a Cost to Charge Ratio. Finally, CMS multiplies the billing charge for a specific CPT code by the Cost to Charge Ratio to calculate the Estimated Cost for a procedure. 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.

Challenges for Coronary CTA Reimbursement

The methodologies currently used by CMS underestimate the costs for coronary CTA and impact the rate at which it is reimbursed. In Nov. 2019, CMS confirmed cuts in the technical component reimbursement for CPT codes 75572, 75573, and 75574. The codes were cut to $182.20, down $19.54 from 2019 rates.
Dr. Dustin Thomas discussed several of the challenges with the methodology CMS is using to reimburse coronary CTA, including the underreporting of costs by healthcare providers, and the inappropriately low charges on CT chargemasters across the country. Dr. Thomas described that there are centers across the US 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.
Coronary CTA, Dr. Thomas continued, is also reimbursed at a rate far lower than other tests. For example, the technical component of Single Photon Emission Computed Tomography (SPECT) is reimbursed at about six times the rate of coronary CTA. This incentivizes providers to invest in tests that will result in better pay.

Help Improve Reimbursement for Coronary CTA

Medical imagers can help improve the rate of reimbursement for coronary CTA by doing the following:
  • Ensure Standardization in Reporting: Capturing accurate data can help contribute to improving reimbursement rates for coronary CTA. Medical imagers should ensure the standardization of protocols, and check that reporting templates align with current SCCT and ACC reporting guidelines.
  • Support Professional Societies including SCCT, ACC, and ACR: Professional societies have committed to continuing advocacy efforts for coronary CTA reimbursement. Collaborate with these groups to participate in helping improve methods for determining accurate costs of coronary CTA.

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.