Payers move to embrace coronary CT angiography

November 1, 2006

Increasing number of state reimbursement policies for CCTA build momentum for national coverage

Increasing number of state reimbursement policies for CCTA build momentum for national coverage

The prospects for reimbursement of coronary CT angiography procedures improved dramatically in 2006. Practitioners in about 75% of the country see some Medicare reimbursement for the procedure, and experts predict that nationwide reimbursement will emerge by 2008 at the latest.

While Category I CPT codes for the procedure do not yet exist, Category III T-Codes, used to track use of a procedure, were issued on Jan. 1. These codes do not have a set dollar amount attached, but most local Medicare carriers provide some reimbursement.

As of late September, only one Medicare intermediary, Noridian, had not issued a Local Coverage Determination for CTA, said Linda Gates-Striby, a specialist in cardiology and interventional radiology coding issues. Montana is the only state that still labels coronary CTA investigational and therefore nonpayable. Medicare LCDs vary in terms of requirements for coronary CTA reimbursement.

At least 14 carriers require the use of 64-slice machines, Gates-Striby said. Others allow the use of 16-slice scanners. Some carriers will pay for calcium scoring, while others will not.

"Every state is different, and that makes it very difficult when you talk about reimbursement," said Cathleen Biga, president and CEO of Cardiovascular Management of Illinois, which provides strategic planning and practice management for about 50 cardiologists in the Chicago area.

Policies can shift quickly as well. Biga cites West Virginia, which originally required the use of a 64-slice scanner, then sent out an amendment allowing physicians to be reimbursed for procedures performed on 16- or 32-slice scanners until 2008.

The dollar amount attached to coronary CTA also varies across the country. Robb Young, senior manager for cardiology CT at Toshiba, estimates that a conservative average for local Medicare reimbursement is $400 to $600, with a few areas reaching $800.

Few private payers have developed national reimbursement policies for coronary CTA, but there has been some movement on a state level. Blue Cross Blue Shield's Web site labels coronary CTA investigational, but some of the state Blues are performing pilot studies or covering the procedure outright, Gates-Striby said. She expects to see more of the Blues begin payment in early 2007.

Biga's group has had some success in contracting with some physician-hospital organizations by using economic impact papers that demonstrate significant cost savings because patients are saved a cardiac catheterization. Economic impact in Biga's practices is about $263 per patient.

"We now have 15 or 16 months under our belt, and we continue to see our diagnostic catheterization rate decrease as our cath-to-intervention rate goes up," Biga said. "This means we are cathing more appropriately."

Much of the movement in the private payer arena is occurring because technical and accuracy studies are being published. The Cardiovascular CTA Data Registry is compiling information from more than 20 sites in 12 states. It has collected clinical indications and economic impact data from almost 14,000 cases so far, said Jeffrey Fine, Ph.D., a cardiovascular physiologist. Fine expects the data to prove the worth of coronary CTA.

"The payers are worried about coronary CTA on two fronts," he said. "The first concern is that the modality is going to be used as a screening test, a blanket catch-all for everyone. The second concern is that it's going to become a layered test, where you order a nuclear perfusion, then a CT, then a diagnostic catheterization."

Fine's data could set payers at ease. In more than 95% of cases he's followed, the coronary CTA has been ordered for shortness of breath, chest pain, known coronary artery disease, or an abnormal function study, all of which fall well within the scope of appropriateness.

CCTA was used as an entry-level test and a substitution for nuclear perfusion in more than 76% of the cases tracked, Fine said. That finding stands to benefit payers because CCTA tends to cost much less than either nuclear perfusion or diagnostic angiography. The results have already had an impact on payers who work with Fine.

"In our latest negotiation, they suggested we skip the middle step of a pilot program where we report quarterly data on coronary CTA and go directly to a policy change," Fine said. "That's a statement that the commercial payers are starting to become aware that the writing is on the wall."

Still, the registry needs more physicians to submit data to allow for a massive review of coronary CT data, Fine said. Those interested should contact Fine at jfine@cvinnovations.net.