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Right to the heart of it

Radiology Administrator's Compliance and Reimbursement Insider, January 1, 2008

CCT and CCTA provide better pictures of the heart

Cardiac computed tomography (CCT) and cardiac computed tomographic angiography (CCTA) offer physicians and patients better pictures of the motion and structure of the heart muscle.

These scans, developed in the early 1990s, revolutionized cardiac imaging and the way the world imagined heart healthcare. CCT and CCTA improved visualization of the heart’s soft tissues and adjacent anatomic structures. Volumetric acquisition associated with this technology permits pictures to be taken from multiple angles and in multiple planes after a single shot. Further, these scans are less invasive than conventional angiography, and thus pose fewer clinical complications.

One way physicians use these cutting-edge exams is to determine the severity of calcium and plaque buildup on the walls and arteries of the heart. If a person builds up enough vascular plaque, the arteries can narrow and may eventually completely block blood flow to the heart.

A tool called calcium scoring helps physicians determine the extent of coronary artery disease early. The amount of calcification, expressed as a score (e.g., the Agatston scale), predicts the likelihood of myocardial infarction in the coming years. However, most payers do not cover coronary calcium scoring (either with or without a CCT or CCTA procedure).

Because the new technology—especially the use of CT for such procedures—gained popularity so quickly, coding confusion seemed inevitable.

To resolve this issue, the American College of Radiology (ACR) recommended reporting the CPT used for CTA of the chest (71275) for CCTA. But it didn’t take the national organization long to rescind its recommendation.

Developing appropriate codes

High-quality CCTA requires different imaging techniques than those used for the examinations described by CPT 71275. The AMA developed CPT 71275 specifically to represent imaging of the noncoronary vessels within the chest (e.g., aorta and pulmonary vasculature), so it is not appropriate to report this code for CCT or CCTA imaging.

A change was made to the description of this code in CPT 2007 to indicate that it is to be used for non-CCTA studies of the chest only. To resolve this conflict, the ACR joined with the American College of Cardiology (ACC) and BlueCross BlueShield to lobby for new Category III CPT codes. The new codes, they said, should describe various common combinations used for CCT and CCTA studies.

The associations were successful. The codes took effect January 1, 2007. And now, at least in most cases, radiologists can use a single code to describe more specific combinations of the services they perform.

Various organizations use the Category III codes (often denoted by four digits followed by an uppercase T) to report and collect data regarding the performance of emerging technologies, services, and procedures. Because the new codes fall into Category III, they represent an “emerging technology.” The AMA and other associations also use the information to track clinical efficacy, utilization, and outcomes.

Without accurate and consistent submission of Category III codes by providers, specialty societies cannot obtain necessary utilization data for these services. It may go without saying, but with no accurate reporting, facilities have difficulty calculating physician work and practice expense information. As of January 1, 2007, the Category III codes for CCT and CCTA must be used because they accurately describe the procedure(s) performed.

Affecting code change

Think of all this in terms of the big picture. Physicians perform a procedure. To receive reimbursement, they must assign a code. To stay compliant, the code must appropriately reflect the services actually rendered. When codes do not accurately reflect current physician practices, medical associations step in to lobby the AMA for new codes.

Reporting and data analysis corroborate the need for the new codes. Without evidence, the AMA may decide to eliminate the code. With enough evidence, the code moves from the “emerging technology” list and into the main body of radiology’s accepted CPTs. A delay in data collection directly results in a delay of Category I code creation for these procedures.

Appropriate and adequate documentation for these services is essential in supporting creation of permanent CPT codes and uniform reimbursement for these studies. Specialty societies such as the ACR and ACC bear the burden of proving to payers that physicians use CCT and CCTA as a substitute for other tests, not just as an additional exam to garner supplemental reimbursement.

Because many ongoing clinical trials are in progress for these procedures, and because sufficient scientific evidence to support the clinical effectiveness and cost effectiveness of this technology is not yet available, the CPT editorial panel is unable to support the creation of Category I codes for the 2008 CPT cycle. Therefore, Category I codes to describe CCT and CCTA services will not be available before January 1, 2009. The ACR and ACC continue to work to obtain the necessary data to move forward with the request for Category I codes.

Besides industry instigation for reporting the new codes, the CPT guidelines require the use of Category III emerging technology codes when they exist: “If a Category III code is available, this code must be reported instead of a Category I unlisted code.”

Additional code use requirements

Associations are not the only ones requiring use of the Category III codes—the federal government also requires it. The Health Insurance Portability and Accountability Act of 1996 standardized the Transactions and Code Sets Rule in 2002. It requires all providers, plans, and payers (including carriers and intermediaries) to use the medical code set that is valid at the time the service is provided. The eight new codes for CCT and CCTA include coronary calcium evaluation (calcium scoring); CCTA (CT coronary angiography); and CT evaluation of cardiac structure, morphology, function, and vasculature.

Codes and definitions

0144T CT, heart, without contrast material, including image postprocessing and quantitative evaluation of coronary calcium

0145T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology

0146T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium

0147T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium

0148T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology and CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium

0149T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology and CTA of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium

0150T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; cardiac structure and morphology in congenital heart disease

+0151T CT, heart, without contrast material, followed by contrast material(s) and further sections, including cardiac gating and 3D image postprocessing; function evaluation (left and right ventricular function, ejection fraction, and segmental wall motion)

Tips: Verify medical policy and conditions of coverage with your individual Medicare carrier. Also, consider collecting at the time of service or offering a discounted rate for patients whose insurance does not cover investigative or elective screening examinations.

Editor’s note: This is an excerpt from the HCPro, Inc., book Cardiac Imaging, Strategies for Appropriate Documentation and Compliant Coding, by Stacy M. Gregory, RCC, CPC. Gregory is an active member of various radiology coding discussion groups and has been featured in several nationally recognized coding publications. To purchase the book, go to www.hcmarketplace.com or call our customer service department at 800/650-6787.

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