Coronary CTA: Drafting the Strategic Plan

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 - Doctor - Heart

Incorporating coronary CT angiography into a cardiology practice’s imaging mix requires a thorough understanding of many things including potential turf issues, siting requirements, workflow and reimbursement. Despite these challenges, cardiovascular programs can maintain a competitive edge by incorporating coronary CTA, especially given the current environment of stiff competition, personnel shortages, overworked staff and decreased reimbursement.

“If you are not developing a business plan for coronary CTA implementation, then you’ve already fallen behind,” says Susan Heck, vice president of Corazon, a Pittsburgh, Penn.-based consulting firm that specializes in cardiovascular program development.

Bringing coronary CTA onboard is a very strategic decision, Heck says, much more than a simple equipment purchase. Some aspects to consider are:

  • Where will the scanner be located?
  • Who will buy it?
  • Who will read the studies?
  • What competency and credentialing
  • criteria will be used?

Coronary CTA has proven valuable to triage low- to intermediate-risk patients with acute chest pain. Should the scanner, therefore, be located in or close to the emergency department? CT also has excelled in pre- and post-operative evaluation of patients undergoing percutaneous or conventional heart surgery. Should the scanner sit within the cardiology department?

Generally, cardiology won’t fill up the CT scanner’s schedule with enough daily coronary artery exams, so the scanner’s time must be shared with general exams. Should the scanner be located in radiology? Will it be used in the outpatient setting or be used in an independent diagnostic testing facility? Are there legal hurdles related to self-referral? What are future plans for the hospital and the technology? Without answers to these questions, practices are setting themselves up to fail.

“I’ve seen practices have to go back to square one because they didn’t conduct a thorough business plan before they bought their scanner,” says Heck.

William Beaumont Hospital in Royal Oak, Mich., has eight CT scanners to service the 1,061-bed teaching hospital. One scanner sits in the Heart and Vascular Center, the other seven belong to radiology. Beaumont avoided turf issues in the Heart and Vascular Center by combining cardiology, interventional radiology and vascular surgery, according to Ralph Gentry, RT, supervisor of cardiac MRI and cardiac CT. The center also saved on siting costs by converting a pre-existing cath lab into a CT suite. An MRI scanner is within close proximity. Gentry calls the center a true one-stop-shop for cardiovascular patients.

Because coronary CTA studies at Beaumont do not keep the scanner busy, the center augments its use with general CT studies, such as chest and abdomen. For coronary CTA, cardiologists read the coronaries, while radiologists overread the thorax. Fees are split: cardiologists get the technical fee, radiologists get the professional fee.

“T” Codes for Cardiac CT

  • 0144T— calcium scoring
  • 0146T— coronaries
  • 0145T— cardiac morphology
  • 0150T— noncoronary congenital studies
  • 0147T— coronaries, calcium scoring
  • 0148T— coronaries, cardiac morphology
  • 0151T—ventricular EF, wall motion

Payback

Three of the biggest challenges of coronary CTA are reimbursement, reimbursement and reimbursement, says Cathleen Biga, president and CEO of Cardiovascular Management of Illinois, a cardiology physician practice management company. The reimbursement world for coronary CTA is unique to each state. Keeping up with the complex and ever changing rules can be difficult.

“I still have people who think they can bill a 71275 [CPT code for chest CT] instead of the proper T code,” Biga says, adding that the T codes have been available for more than two years.

Having the right code is the first part of the equation because policies vary on the number of T codes for which they allow billing. The second part of the equation is having the right indication for the test. The indication must match the Medicare local coverage determination (LCD) for your state and/or private payor medical policy. The clinical indications can vary from payor to payor—private or government. Some payors, for example, may allow a CT scan following an indeterminate nuclear stress test, while others may not. The third part of the equation is to have the appropriate diagnoses.

“It’s important to read the policy,” Biga says. “It could say that the only diagnosis acceptable for coronary CTA is for the presence of coronary artery