Economics of Cardiac CT Pamela K. Woodard, M.D., FACR Mallinckrodt Institute of Radiology St. Louis, MO

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1 Economics of Cardiac CT 2011 Pamela K. Woodard, M.D., FACR Mallinckrodt Institute of Radiology St. Louis, MO

2 Cardiac CT CPT Codes ordering and reimbursement patterns.» Who s ordering?» Who s being reimbursed? CMS initiatives that affect cardiac CT imaging. What to do if you get a RUC survey (or, what is a RUC survey anyway??)

3 Category I Cardiac CPT Codes ACR/ACC presented Category I codes to AMA CPT Editorial Panel October 25, These codes were approved and went to RUC (Relative Value Update Committee), January 30, Codes went into effect, January 2010.

4 Category I Cardiac CPT Codes CT, heart, without contrast material, with quantitative evaluation of coronary calcium CORONARY CALCIUM CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, cardiac function, and evaluation of venous structures, if performed) MORPHOLOGY, PULM VEINS CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, LV cardiac function, RV structure and function and evaluation of venous structures, if performed) CHD CTA, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post-processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CORONARY ARTERIES (CCTA)

5 What do we know about ordering patterns and CMS reimbursement of cardiac CT cases? Annual Medicare Physician Supplier Procedure Summary (PSPS),

6 CCTA CPT codes (Category III Emerging Technology) 0144T CT angio calc scoring without (non-covered) 0146T CCTA alone 0147T CCTA with calcium scoring 0148T pulmonary veins, includes CCTA 0149T pulmonary veins, includes CCTA and calcium scoring 0150T congenital studies, noncoronary +0151T CT angio heart for cardiac function plus 3d & function eval (add-on code, not reported alone)

7 National annual Medicare fee-for-service cardiac CT submitted and denied claims Denial rates are estimated by dividing denied by submitted claims. Duszak R et al, Cardiac CT and coronary CTA: early Medicare claims analysis, JACR, 2011 (Analysis of Annual Medicare Physician Supplier Procedure Summary (PSPS), )

8 Total number of three-year Medicare fee-for-service claims for cardiac CT and CCTA (in parentheses), with denial rates over time ( ), by CMS geographic region.

9 Annual cardiac CT Medicare fee-forservice claims, by provider specialty. Duszak R et al, JACR, 2011 Analysis of Annual Medicare Physician Supplier Procedure Summary (PSPS),

10 Annual cardiac CT Medicare fee-forservice claims, by site of service. Duszak R, et al, JACR, 2011 Analysis of Annual Medicare Physician Supplier Procedure Summary (PSPS),

11 CMS Initiatives with Impact on Cardiac CT Imaging

12 Equipment Utilization Rate Increase November 25, 2009 final rule, CMS raised the advanced imaging (MRI/CT/PET) equipment utilization rate from 50% to 90%. This change from 50% to 90% was going to be phased-in over 4 years.

13 What is a utilization rate? General assumption of what percentage of time equipment (MRI/CT/PET) is in use. An average rate applied nationally and used to calculate office -based outpatient technical reimbursement rate (inversely proportional to utilization rate). Utilization rate ; reimbursement down

14 Last year at this time utilization rate was at 62.5%. Affordable Care Act (July 2010) overrides this rule.

15 Good news/bad news -- Affordable Care Act (July 2010) overrides this rule. The Affordable Care Act adjusts the equipment utilization rate assumption for CT/MR/PET (all equipment > $1 million) Effective January 1, 2011, CMS assigned a 75 percent equipment utilization rate assumption to diagnostic computed tomography (CT) and magnetic resonance imaging (MRI) services.

16 This Summer Congress Tried to Raise Utilization Rates Again!

17 Mixed News -- Rate stays at 75%, but higher than ever before. Outpatient office-based physicianowned CT equipment no longer tenable as a business model.

18 Additional Affordable Care Act: Multiple Procedure Reduction Rule On July 1, 2010, the Affordable Care Act increased the established MPFS multiple procedure payment reduction for the technical component of CT single-session imaging services to consecutive body areas from 25 to 50 percent for the second and subsequent imaging procedures performed in the same session ie; C/A/P

19 Think that this won t affect Cardiac CT? CMS expanded this policy to noncontiguous body areas and across modalities on the same patient, same session performed by the same physician effective January 1, MedPAC recommended in March that the MPPR be applied to PROFESSIONAL COMPONENT.

20 And.... CMS is soliciting comments on the following expanded MPPR policies which will appear in future rulemaking:» Apply the MPPR to the Technical Component of ALL imaging services;» Apply the MPPR to the Professional Component of ALL diagnostic services furnished during the same encounter;» Apply the MPPR to the Technical Component of ALL diagnostic services.

21 Misvalued CPT-Codes Goal: Identify and adjust values of over-priced physicians services. Focus on specific codes for RUC Review» Fast growth» New technologies or services

22 What s Up for Review? Cardiac CT CPT Codes not on the list for RUC Review this fall. Cardiac MR CPT Codes ARE on the list for consideration as are other CT angiography codes. What should you do if you get a RUC Survey?

23 Complete it! RUC Survey

24 What is it used for? Will come from ACR or ACC. Important to be completed accurately. Important to be completed on time. Results will affect CPT code valuation. Results will affect reimbursement.

25 Understanding the RUC Survey Instrument May 2010

26 Other CMS Initiatives Patients and Providers Act, July 2008 Imaging Lab Accreditation required as a condition for reimbursement 2012» Accreditation: ACR, Intersocietal Commissions (ICACTL, etc.)

27 What Else Can I Do? Keep abreast of your society s advocacy activities. Provide comments to CMS when needed.