In a changing world, outpatient practices embrace cardiac CT

Nonacademic private practice groups performing cardiovascular imaging studies have flourished during the past 30 years. As more practitioners entered private practice to meet growing demand and more hospitals developed advanced heart programs, cardiovascular services became increasingly accessible across the U.S. Along with this growth, these groups began to move noninvasive imaging out of the hospital and into their own offices. Echocardiography was the first imaging service to move to the outpatient setting, followed by SPECT. Today, many cardiology, radiology, and vascular surgery groups are adopting multislice CT to enhance their patient management.

Cardiovascular MR emerged in the 1990s as a highly specialized, expensive imaging modality for a limited scope of cardiac-related applications, such as myocardium viability, perfusion, and function. CMR also performs angiography studies, but MRA for the native coronaries was not adequate. MRA applications were not widely used, since few physicians have developed vascular disease services at a high level within their clinical practice. Currently, most CMR units (1.5T or better) are operated within a hospital or academic setting, with little integration on the ambulatory side. This is a reflection of both the low volume of CMR procedures generated by most groups and the difficulty in operating a CMR unit profitably, because of the high cost of the technology and difficulty in securing adequate third-party payer reimbursement.

Multislice CT technology intoduced in the late 1990s quickly evolved to provide results equivalent to EBT for coronary calcium scoring. As spatial and temporal resolution improved, MSCT technology entered the noninvasive diagnostic coronary angiography arena. With the advent of 64-slice technology in 2004, MSCT applications within cardiovascular imaging quickly became known as cardiovascular CT, and many luminary cardiologists and radiologists have proclaimed that the era of noninvasive coronary angiography is here.

Since January 2005, developments on the cardiovascular CT front include formation of a new society (Society of Cardiovascular CT), publication of physician competence guidelines from the American College of Radiology and the American College of Cardiology, new CPT codes, a national model local coverage determination (LCD) for coronary CT angiography, the release of numerous local carrier determinations by Medicare intermediaries across the U.S., the publication of clinical appropriateness criteria for coronary CT angiography, and the approval of coronary CT angiography for reimbursement by several commercial payers.

DRIVING FORCES

Two primary forces are driving the adoption of CVCT services within the ambulatory setting: clinical and scientific evidence; and billing, coding, and reimbursement policies.

With strong leadership and expert input from the SCCT, various organizations offer timely guidance to clinicians and payers on the emerging role of CVCT, in particular coronary CTA. This clinical and scientific information serves to instruct cardiologists, radiologists, vascular surgeons, and payers regarding the appropriate use of CVCT technology in day-to-day practice. Private practice groups can refer to the published information to develop coronary CTA ordering and interpretation skills. More important, they can receive direction on the appropriate use of coronary CTA exams based on the developing knowledge of physician leaders who understand the strengths and weaknesses of CVCT technology.

Armed with this clinical foundation, medical directors for health insurance companies and health plans can analyze CVCT technology and develop informed medical policies for coronary CTA services. The combination of American Medical Association-approved and dedicated CPT codes for coronary CTA applications with the ACC/American Heart Association's published clinical appropriateness criteria will advance the adoption of coronary CTA medical policies. Although Blue Cross/Blue Shield, along with several other national health insurers, currently classifies coronary CTA as investigational and experimental, some BC/BS franchisees have decided to reimburse coronary CTA services under certain conditions.

As more clinical data emerge, more health insurance companies will adopt national coverage policies for coronary CTA. Many medical policy or coverage decisions are made on a local level by self-insured employers. As more hospitals and private practice groups offer coronary CTA studies using 64-slice or better technology, they will meet with these self-insured employers and cooperatively establish coronary CTA coverage and reimbursement policies. Widespread coronary CTA clinical adoption and reimbursement are not a matter of if but when.

A secondary force contributing to an accelerated adoption of CVCT in the ambulatory setting is financial. Technical fee reimbursement for SPECT and echocardiography services has reached its peak. The cost-cutting measures contained within the Deficit Reduction Act of 2005, coupled with changes in practice expense relative value units, will result in a decrease in excess of 25% in the technical fees for SPECT perfusion imaging and echocardiography. CVCT imaging offers the opportunity to capture technical fee profits that will help offset losses from SPECT and echocardiography services.

NEW CLINICAL MODEL

Ambulatory cardiovascular imaging for the next 10 years is likely to include three primary modalities:

• cardiovascular ultrasound for functional assessment, including echocardiography, transesophageal echocardiography, carotid duplex scanning, and lower extremity studies;

• nuclear cardiology for physiologic studies, including perfusion (SPECT and PET) and viability (PET only); and

• cardiovascular CT for anatomic and noninvasive angiographic studies, including coronary CT angiography, contrast-enhanced cardiac imaging, and CTA of other great vessels.

Although a growing number of groups are involved with outpatient cardiac catheterization laboratories, most have not integrated a cath lab into their ambulatory imaging services. Reasons for this vary but they do not apply to CVCT, which offers groups that will not or cannot pursue an ambulatory cath lab a new way into the angiographic imaging business: noninvasive, or CT, angiography. Coronary CTA will provide highly sensitive, highly specific, and conclusive findings when used according to recently published clinical appropriateness criteria.

CVCT PRACTICAL ISSUES

Many practical issues relate to CVCT in the ambulatory setting.

• Marketing. Other than coronary calcium scoring, CVCT services should be marketed to referring cardiologists, vascular surgeons, and primary-care and other physicians using a physician education program with no direct-to-consumer marketing. This program typically includes CME events, grand rounds, meetings with individual groups, open house events showcasing the CVCT technology, and case presentations with CTA images.

• Image interpretation. Most cardiology, vascular surgery, and radiology groups have resolved this issue in a collaborative fashion. While third-party payers and professional organizations debate issues around split interpretations, various successful interpretation models are employed. Some radiologists involved in CVCTA interpret the entire data set of images. Others provide soft-tissue overreads for a fixed fee. In this case, the group operating the CVCT service then bills globally (professional and technical) for each CTA. The radiologist is paid for the overread service whether or not the group operating the CVCT receives a payment for the procedure. The overread fee is fixed.

• Location of the service. CTA services require onsite physician supervision. The supervising physician must be within the office location or address where the CT unit is located but not necessarily in the CT lab. Therefore, in most cases, private practice groups will opt to locate the CVCT service within or adjacent to one of their existing offices. An ideal option is in office space adjacent to a hospital. This provides an opportunity for the CVCT equipment to serve both outpatient and hospital needs, avoiding duplication of equipment and greatly reducing the cost per CT scan.

• Workstations. Most cardiologists and vascular surgeons are not yet as comfortable as radiologists in reading images on workstations. OEM workstations are typically designed by and for radiologists who interact with CTA images in a manner distinctly different from that of cardiologists. In CVCT, most cardiologists and surgeons are more comfortable with workstation equipment not supplied by the OEM. Vital Images and TeraRecon build CVCT workstations that can be used on any CT equipment.
• Patient prep and management. The primary patient preparation issue to contend with is heart rate control. Generally, it is important to get the coronary CTA patient's heart rate down to 60 bpm. For most patients, this involves a protocol incorporating oral beta blockers, but intravenous beta blockers must be administered in some situations to achieve the target heart rate. Patient prep should be done by an experienced nurse or nurse practitioner. Most of the patient prep functions should be done in an area adjacent to, rather than within, the actual CT lab to minimize the amount of time each patient spends within the lab for maximum throughput. Having more than one patient prep room allows one nurse to prep and recover several patients at the same time.

• Contrast selection. Much misinformation continues to be distributed about contrast administration. In general, higher contrast concentration produces better images, especially with coronary CTA studies. Some have suggested that it may be difficult to achieve or maintain good heart rate control with all low-osmolar contrast media (LOCM). This is not true, as experience has shown that all LOCM are not the same when it comes to this issue.

FUTURE ROLE

Many factors predict that CVCT will become the third major imaging service to migrate into the ambulatory setting. Cardiovascular ultrasound and nuclear imaging are operated in almost every cardiovascular office in the U.S. During the next five years, CVCT will join these two modalities and embed itself as a mainstream ambulatory imaging service.

Mr. Attebery is founder and president, and Dr. Fine is vice president of Cardiovascular Innovations, a company that provides training and education for cardiovascular CT in Beaufort, SC. They can be reached at tattebery@cvinnovations.net and jfine@cvinnovations.net.