Insurer seeks ACR input on coronary CT angiography

October 3, 2006

One of the largest health insurers in the U.S. has solicited the American College of Radiology for its opinion regarding who should read coronary CT angiography studies.

One of the largest health insurers in the U.S. has solicited the American College of Radiology for its opinion regarding who should read coronary CT angiography studies.

Highmark, which serves more than 50 counties in Pennsylvania, sent a draft of its Guidelines Specific to Cardiac CT to the ACR, requesting input on appropriate privileging and policy guidelines for reimbursement on coronary CTA.

In discussions with the ACR, Highmark had indicated it was considering two options: allow a radiologist to interpret the entire cardiac CT or coronary CTA study, or allow a cardiologist to read the cardiac images and contract with a radiologist to read the noncardiac portion of the study.

The ACR responded in a letter in late summer that a properly trained radiologist is the best qualified physician to supervise and interpret the full data set of images involved in cardiac CT and coronary CTA.

The ACR noted, however, that other physicians may gain the requisite training and experience set forth in its practice guidelines.

The letter states that the position of the ACR and of the American College of Cardiology is that a single physician should be responsible for the interpretation of cardiac CT and coronary CTA exams. A model local coverage determination jointly written by the ACR and the ACC and distributed to all Medicare carriers in December 2005 also supports this position.

Dr. Paul A. Larson, chair of the commission on quality and safety, and Dr. John A. Patti, chair of the commission on economics, signatories of the letter, state their concerns with the legality of split interpretations. They say there is no provision in the code descriptors to allow for this practice.

"The descriptors ... absolutely require interpretation of all axial source and reformatted images. Any physician who performs less work and submits a claim for full payment is at risk for filing a false claim," the letter said.

The ACR also has concerns regarding liability should two physicians interpret one exam.

One option given by the ACR is for a radiologist to interpret the entire set of images and for a cardiologist to provide an overread of the cardiac structures as an adjunct to the radiologist's interpretation.

"We can understand why both organizations are interested in the issue," said Michael Weinstein, a spokesperson for Highmark.

Weinstein noted the ongoing debate about the proven scientific value of coronary CTA to patients. Highmark still considers it an experimental treatment, but the company is monitoring the peer-review data closely.

"We have not seen sufficient scientific evidence to determine the procedure improves patient outcomes," Weinstein said.

For more information from the Diagnostic Imaging archives:

Practice tips: Navigating reimbursement now

Reimbursement cuts could make exams money losers

Rivalry between ACC, ACR surfaces at founding meeting

Cardiac CTA screening pays off if price is right