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 disease. Therefore, any claims with ‘chest pain’ as the diagnosis will be denied.”

Other examples of variable requirements from state to state include:

  • Technical—Many payors require at least a 64-slice scanner, some require spatial resolution of 1 mm or less.
  • Clinical—Some payors will reimburse for beta blocker administration when billed separately, others are very specific that it cannot be billed separately.
  • Supervisory—Some mandate direct supervision of CT scans by physicians, others are silent about it.
  • Competence—Some require physicians to be credentialed (the American College of Cardiology and the American College of Radiology each have separate requirements for their respective specialties) in order to supervise and interpret the test, others do not specify such a mandate.

To make matters even more complicated, the government is integrating the use of Medicare Administrative Contractors (MAC). In Illinois, for example, it’s possible that a provider could have their Medicare part A under one LCD and their Medicare part B under another LCD. If a different insurer wins the MAC integration contract, it would give the provider a third LCD to contend with, Biga says.

Another step in the process is going through the various radiology business managers (RBM) that insurance companies hire to vet claims prior to the imaging study. After providers discern whether their carrier covers the indicated coronary CTA, they then sometimes have to call the RBM to get approval for the test. If the RBM doesn’t agree the test is necessary, a game of tag ensues where the physician from the practice and the physician from the RBM try to have a peer-to-peer review. And even if the provider is granted a radiology quality initiative (RQI) number to go ahead with the exam, it still might be denied later, Biga says.

Advanced CT Technology Keeps Radiation Dose Low

While radiation dose of coronary CTA is a concern, retrospective ECG-gating with dose modulation and prospective ECG-gating with step-and-shoot protocols have reduced dose to as low as 3 to 5 mSv—that's lower than most catheter angiography procedures.

Even the latest slice iteration—the 320-detector row scanner from Toshiba America Medical Systems—can feasibly deliver an effective dose of 4 mSv, according to a study by Frank Rybicki, MD, PhD, director of the applied imaging science laboratory, and colleagues at Brigham and Women's Hospital (Int J Cardiovasc Imaging 2008;online:Mar 27).

Dollars and sense

A concern of payors is that cardiac CT, particularly coronary CTA, will be used indiscriminately along with other well-established imaging tests. The evidence, however, doesn’t bear that out. Analysis of a coronary CTA registry containing data for more than 25,000 patients found that less than 1 percent of exams were used as a layered test, meaning inappropriately ordered on top of other tests. The majority of the coronary CTA exams in the registry were used appropriately:

  • CTA was performed as a stand-alone test in 69 percent of patients;
  • CTA was performed after an inconclusive SPECT exam, essentially as a cath substitute, in 16 percent of patients;
  • CTA was performed as a first test, then cath, essentially acting as a SPECT substitute, in 9 percent of patients; and
  • CTA was performed first with inconclusive results, followed by a SPECT exam in 5 percent of patients.

“The average savings per diagnostic episode was $442,” says Timothy Attebery, who is involved with the CCTA Registry and is president and CEO of CVI3, a firm that provides training and education for cardiovascular CT.

The impact coronary CTA has on a cardiology practice can be gauged by the percentage of normal caths. If coronary CTA is used successfully to triage low- to intermediate-risk patients away from catheter angiography, the number of normal diagnostic caths should be reduced. Figures from the CCTA Registry show a 6 percent decline in normal caths, while therapeutic caths increased 13 percent. 

chart

But how does coronary CTA compare with the gold standard? In the first prospective, multicenter study comparing 64-slice coronary CTA with quantitative coronary angiography, reported at the ACC meeting, researchers found that CTA consistently demonstrated high accuracy to detect stenosis (>50 percent and >70 percent) in chest pain patients being referred for invasive coronary angiography. The study, which enrolled 232 patients from 16 academic and private practice sites, did not exclude any patients based on high heart rate, high baseline calcium score or high body mass index. Additionally, researchers included all vessel segments in the analysis irrespective of size, says James K. Min, MD, a cardiologist at Weill Cornell Medical College in New York and lead author of the study.

“We’ve established CTA’s diagnostic accuracy and now we need to prove that it’s clinically useful,” Min says. That can be done in three ways. First, prove it’s more cost-effective to use CTA as a first line test. Second, demonstrate that the findings on coronary CTA have prognostic value. And third, conduct prospective randomized trials comparing CT with the standard of care.

Min and colleagues presented another study at the ACC meeting where they found that patients with no known coronary artery disease who undergo coronary CTA as a first-line test incur lower costs compared to CAD-naïve patients who undergo SPECT imaging initially. In contrast, patients with known CAD who undergo SPECT initially incur lower healthcare costs than if they’d had a first-line CTA study.

A study from researchers at Cardiovascular Medical Group of Southern California found that the volume of SPECT imaging dropped significantly by 15 percent within the first year after the integration of a 64-slice CT scanner into an office-based practice. Standard treadmill testing significantly decreased as well, while exercise echo volume increased slightly. Interestingly, net office income did not decrease significantly. Ronald P. Karlsberg, MD, reported at the ACC meeting that the potential for further reduction in SPECT imaging is substantial and that “coronary CTA as the first and often only test for the intermediate-risk patient warrants prospective study.”

CCTA: A Good Value

Medicare reimbursement rates for the 2008 calendar year are set at:

  • Coronary CTA: $650
  • SPECT myocardial perfusion imaging: $1,096
  • Invasive coronary angiography: $2,860

What to buy

Practices that incorporate CT “anticipate spreading lease or debt payments over the course of 60 months to keep equipment expenses in reasonable relationship to revenues,” according to Timothy M. Bateman, MD, at Saint Luke’s Mid America Heart Institute in Kansas City, Mo. (J. Am Coll Cardiol Img 2008;1;111-118). This financial arrangement was problematic with early adopters of 4- and 16-slice technology, Bateman says, because of the rapid depreciation of the scanners upon the introduction of 64-slice scanners. How long 64-slice CT will remain cutting edge remains unclear, particularly with dual-source scanning–which uses two x-ray sources that deliver a higher temporal resolution–from Siemens Healthcare and a 320-detector row scanner from Toshiba America Medical Systems.

Sanford USD Medical Center in Sioux Falls, S.D., is in the midst of constructing a Heart and Vascular Hospital to be attached to the main 500-bed medical center. They currently perform about 250 coronary CTA exams per year and would do more if insurance covered more indications. They will install at least one CT scanner in the new heart hospital, but which iteration of technology has not been decided. “We are in constant contact with consultants as to the state-of-the art and we want to remain flexible,” says Charles P. O’Brien, MD, president of Sanford and an invasive cardiologist.

The projection for year 2009 cath lab procedures is this:

  • 3,329 diagnostic caths
  • 1,258 interventional caths
  • 918 electrophysiology cases, and
  • 3,999 peripheral cases

Within five years, O’Brien expects the number of diagnostic caths to top 5,000. How will cardiac CT affect those numbers? He’s not sure yet, but he knows that his region is in the midst of a growth spurt, that his cardiovascular business is increasing and that CTA must fit in somewhere.

“We have to recognize that cardiovascular disease is the No. 1 cause of death in the U.S. and the need for an accurate diagnosis is key to manage these patients,” says Tom Stys, MD, Sanford’s medical director of cardiovascular services. “CTA complements many different technologies, so we know we have to make a place for it.”

O’Brien and Stys also like CT for what it can do beyond diagnosing coronary artery disease. They will most likely include CTA in the new cath lab. “Having CT in the cath lab allows you to see into lesions better, particularly single and double occlusions,” Stys says. “Knowing the composition of the plaque, whether there is more or less calcium, will allow interventionalists to be more accurate with their wires.” CT is much more than a triage tool, he said.

While the nature of rapidly changing technology might keep many facilities like Sanford USD Medical Center from committing to a particular piece of equipment, it hasn’t dampened their commitment to having the best cardiovascular imaging technology. Today, that has to include CT.

Private Practices Must Have the Referrals

Before a private practice invests in a CT scanner, it should ensure it will generate enough referrals and have a CT champion onboard, recommends Vance Chunn, CEO of Cardiology Associates, a 28-physician practice in Mobile, Ala.Chunn also acknowledges the importance of knowing the cost, not just of the scanner but of any site construction, added personnel and physician training. The last step is to conduct a proforma that shows the scanner will be profitable, he says.

Cardiology Associates was the first private practice group in the U.S. to purchase a GE Healthcare LightSpeed VCT about three years ago. Initially, the group eyed cardiac MRI, but gradually switched to CT as they conducted their research.

They've had difficulty getting local radiology groups to provide "supplemental" reading of soft tissue, bone and other structures associated with coronary CT angiography imaging. To date, only one local group has accepted their offer, otherwise, the supplemental reading goes to a radiologist in neighboring Louisiana. They bill globally for CTA procedures and pay the radiologists a set fee.

The group performs about six to eight coronary CTA exams daily. The scanner also is used to image the head, chest, lower extremities and peripheral vascular territories. The group has found CT imaging to be particularly advantageous in pre- and postoperative electrophysiology and peripheral vascular procedures.