Payers slowly embrace CT angiography

The prospects for reimbursement of coronary CT angiography procedures improved dramatically in 2006. About 75% of the country sees 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 the usage 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 July, only one Medicare intermediary, Noridian, had not issued a Local Coverage Determination (LCD), said Linda Gates-Striby, technical editor for the cardiology and interventional radiology coders pink sheets. 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.

"We've heard there have been areas that have been as high as $800, but it's not widespread," he said.

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 technical Web site labels coronary CTA investigational, but some of the state Blues are doing pilot studies or covering the procedure outright, Gates-Striby said. She expects to see more of the Blues begin payment this year and in early 2007.

Biga's group has had some success with carveout contracts with some PHOs by using economic impact papers that demonstrate significant cost savings because patients are saved a cardiac catheterization. Economic impact in Biga's two practices added up to 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. A coronary CTA data registry is compiling information from more than 15 sites in 10 states. It has collected clinical indications and economic impact data from almost 10,000 cases so far, said Jeffrey Fine, Ph.D. a cardiovascular physiologist and vice president of Cardiovascular Innovations. 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 should set payers at ease. In more than 85% of cases he's followed, the coronary CTA has been ordered for shortness of breath, chest pain, known CAD, or an abnormal functions study, all of which fall well within the scope of appropriateness.

Coronary CTA was used as an entry-level test and a substitution for nuclear perfusion in more than 76% of the cases tracked, Fine said. That stands to benefit payers because coronary CTA tends to cost much less than either nuclear perfusion or diagnostic angiography.

The results have had an impact on the payers that Fine works with.

"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."