Practice tips: Navigating reimbursement now

September 22, 2006

Experts agree: Coronary CT angiography is on track to be reimbursed throughout the country, by both Medicare intermediaries and private payers, by the end of 2008. But what can providers do to deal with reimbursement issues now, when payment is still up in the air?

Experts agree: Coronary CT angiography is on track to be reimbursed throughout the country, by both Medicare intermediaries and private payers, by the end of 2008. But what can providers do to deal with reimbursement issues now, when payment is still up in the air?

We talked with Tim W. Attebery of Cardiovascular Innovations in Beaufort, SC, a firm that helps cardiovascular and radiology practices navigate the fast-changing world of coronary CTA and other emerging technologies.

Cardiovascular Imaging: How do you recommend practitioners approach billing now that the new t-codes have been introduced but reimbursement isn't guaranteed?

Attebery: My advice is to stay away from the temptation to bill the coronary CTA as a chest CTA. If the presenting condition of the patient is such that a chest CTA is indicated, then do it. However, if it's being ordered for rule-out purposes of coronary artery disease, and you're going to do an evaluation of cardiac and angiographic findings, billing it as a chest CTA is inaccurate and fraudulent. Groups that don't follow this advice have been asked to refund money.

Before the t-codes were instituted, the recommendation was to bill the unspecified codes. Now that the t-codes have been released, Blue Cross, Aetna, Cigna, and the American College of Radiology have all issued statements to providers saying, "Do not use 71275 as your code for coronary CTA." Start billing using the t-codes even if payment is denied.

CI: Right now, are cardiologists who are performing this test losing money?

Attebery: Yes. A hospital or an imaging center probably is not losing money when you add up technical fees from all CT services. A cardiology group that buys a CT today will be in the red the first year. The second year, they'll probably start to break even, and the third year, they'll start to come out of it.

CI: If they're losing money, why do it?

Attebery: This is all part of a paradigm shift in cardio disease management. For 40 years, we've been focused on stenotic lesions. Almost everything we've done, both in imaging technology and in therapeutic approaches, has been focused on identifying and therapeutically addressing a stenotic lesion. What the system is slowly shifting to is the realization that total plaque volume is probably more important. That's what coronary CTA shows.

If you want to be part of the first wave and be a leader in your community and drive this paradigm shift, take the gamble.

CI: What advice would you give to radiology and cardiology practices thinking about entering the field?

Attebery: If you've never owned a CT scanner before, be very careful about buying one right now, particularly as a non-hospital-based operation. If you've never operated it before, buying a scanner at a $1.5 million investment is a big risk. If you're a big cardiology group and have a lot of physicians who could support it, you could probably stumble your way and get through the first couple of lean years. If you're a modest-sized group, let's say fewer than 10, you probably ought to think twice about it.

CI: What about radiology practices?

Attebery: For a radiology practice, it's a no-brainer. If they already have multislice CT, the incremental cost of upgrading to a 64-slice scanner is marginal. For a hospital, imaging center, or radiology group to replace one multislice scanner with a 64-slice scanner is not that much of a gamble. This is probably a safe way in many communities for this technology to be introduced.

CI: What other reimbursement land mines do practitioners face?

Attebery: Right now, there's one interpretation fee, but you can have two interpreters. When you do a coronary CTA, you're going to visualize a part of the soft tissue that surrounds the heart, so a cardiologist is going to need a radiologist to perform the overread. That radiologist overread is not a separately billable service under the current coding.

CI: How do you suggest groups handle this?

Attebery: It's a controversial issue. My advice, where you can do it, is to make coronary CTA a collaborative effort. Radiologists who try to block out the cardiologists will have short-lived success. Cardiologists who try to block out the radiologists are going to have problems in performing and interpreting the tests, because it's a service they're not used to doing. The integrated approach is best.

CI: How should groups deal with the financial side of this issue?

Attebery: I advise hospitals to enter into a professional services agreement with both cardiologists and radiologists and pay them each for their separate interpretation. Until such time as the codes get clarified and you can bill for these services separately, they should bill globally and pay each practitioner for the professional services based upon a fair market value.

CI: And private practices?

Attebery: Private practices should negotiate. For example, a cardiology group should enter into a professional services agreement with a radiologist. The radiologist will accept a specific fee for providing the soft-tissue overread. That radiology group should get all of the other interpretation services that the cardiologists don't do. A lot of cardiology groups order carotid or runoff CTAs, but they can't read them. Let the radiologists read all of those and bill for it. Negotiate a lower fee on the coronary CTA soft-tissue overread in exchange for that radiology group getting the contract for all the other interpretations.

Participants at our workshops say the going rate for that professional soft-tissue overread service is somewhere between $40 to $60. So, for example, in Tennessee, Medicare allows somewhere around $700 for a global coronary CTA with wall motion and ejection fraction. If you have to pay the radiologist $50, you still have $650 left from your global fee. Not bad.