CCTA needs outcome data for payor reimbursement

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Michael Poon, MD, discussed the Centers for Medicare and Medicaid Services (CMS)-approved billing codes and standards for cardiac CT angiography (CCTA) on Saturday during the Transcatheter Cardiovascular Therapeutics (TCT) conference in Washington, D.C.

Poon first reviewed the history of CT codes. In 2003, the CMS borrowed approved billing codes from New York and New Jersey, and specifically code 71275 from radiology for the first billing code for CT. At the time, the CMS focused on stress tests.

Currently, 8 million stress-rest myocardial perfusion SPECT studies are performed each year, according to Poon. He also reported that there are 8 million cardiac catheterizations performed annually, with 25 percent implemented in the United States.

CCTA needs outcome data, according to Poon, who said that it takes time to prove that this approach improves outcomes. He also said that many providers still consider CCTA as investigational, without proof of outcomes.

 In 2005, the American College of Cardiology (ACC) and the ACR began collaborating on a draft for Model Medical Policy Local Coverage Determination (LCD). Poon reviewed the temporary tracking codes, which vary according to states, currently including the following standards:
•    CCTA used as a first test to assess the cause of chest pain.
•    CCTA used as a triage tool to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.
•    CCTA to evaluate the cause of symptoms in patients with known coronary artery disease (CAD).
•    CCTA to evaluate the cause of chest pain or dyspnea in patients with prior bypass surgery or intracoronary artery stent placement.
•    Poon highlighted the coronary stent variables; different sizes and shapes. He also said that the diameter of the stent is the most important aspect of its evaluation, and stressed that the diameter should not go below 3mm.
•    CCTA for suspected congenital anomalies of the coronary circulation.
•    CCTA for evaluation of acute chest pain in the emergency room.
•    CCTA for the assessment of coronary or pulmonary venous anatomy.
•    Use of CCTA prior to non-coronary artery cardiac surgery.
•    Quantitative evaluation of coronary calcium to be used as a triage tool in patients with typical chest pain and unknown Agatston score to determine appropriateness of CCTA vs. catheter coronary angiography.

Poon said that patients with a lot of calcium should not receive a CT scan. He also said that after the Deficient Reduction Act of 2005, which cut $160 million for imaging, no state, except California, cover for calcium. Along the same vein, Poon said that private payors are the best reimbursing imaging modalities.

Quantitative evaluation of coronary calcium to be used as a triage tool for lipid-lowering therapy in patients with moderate to high Framingham Risk score.

Poon said that the objective of the appropriate criteria is: used as supportive decision and education tool when ordering a test; used as a guide referring physicians, who had ordered the test inappropriately; and finally, to establish a standard protocol.

According to Poon, the current triple rule approach has “no data to support” it, and even called it a “shotgun approach.” He said the breath hold is too long, and the contrast feed lasts too long.

Poon announced that the “Multi-Modality Appopriate Criteria” will be issued by the ACC soon.