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Keeping beat with cardiac imaging

Radiology Administrator's Compliance and Reimbursement Insider, September 1, 2006

Understand code changes to reap reimbursement

There’s no denying that cardiac imaging is the next big development in healthcare.

“Radiology is one of those fields [in which], when something new comes out, everyone has to have it. [Most] consumers are well aware of the improvements in cardiac imaging technology. They want the latest noninvasive scan,” says Stacy Gregory, RCC, CPC, president of Gregory Medical Consulting Services in Tacoma, WA.

That’s why Medicare and other payers watch reimbursement for cardiac imaging procedures so closely, she says.

“Heart image codes are among the most used, which is probably why CMS put them on its most watched list,” said Walter C. Blackham, MS, RCC, president of Specialty Medical Services, Inc., in Lorain, OH, during the June Radiology Business Management Association meeting in Miami.

Straight from the heart

Concern over compensation associated with cardiac imaging is one of the biggest issues in imaging today, says Shelley Weiner, MD, FACR, senior medical director at CareCore National in Wappingers Falls, NY.

Although government and private payers are beginning to provide payments and guidance concerning such innovative imaging procedures, financial support varies according to carriers coverage policies.

“Technology is changing so fast, and the rules are changing just as fast,” says Diane Millman, an attorney with Washington, DC–based Powers Pyles Sutter & Verville, PC, who represents an association of cardiologists.

“It’s a ‘now you see it, now you don’t’ world in terms of technology,” she says.

Because of this increased public interest, the American College of Radiology and American College of Cardiology joined forces with BlueCross BlueShield to create new Category III CPT codes for cardiac imaging.

The new codes, which took effect January 1, describe various common combinations of cardiac CT and CTA studies, says Gregory.

In most cases, the CPT uses a single code to describe the combination of services performed.

Battle plans

Just knowing the codes may not be enough to win you compensation for cardiac imaging procedures, warned Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, of Coding Strategies, Inc., in Powder Springs, GA.

Mulaik presented diagnostic coding conundrums during the American Healthcare Radiology Administrators’ audioconference “Diagnostic Radiology: Hot topics and updates” on June 28.

“We are not seeing across the board that people are getting reimbursement for these procedures,” she said.

“It may be a really great procedure but we’re just beginning to find out what’s being paid and what isn’t in regard to CT/CTA coronary.”

There are no relative value units for Category III CPT codes, said Mulaik.

Physician reimbursement for these services depends on carrier fee schedule and local coverage determinations (LCD) requirements, she said.

The majority of payers—private and Medicare alike—do not currently reimburse for cardiac CT angiography (CCTA) or calcium scoring, says Gregory.

Blackham said most payers appear willing to pay for CPT code 0146T—CT, heart, without contrast material, followed by contrast materials 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.

“[Because] it’s the most popular study, it’s probably also going to be the most watched study, as well,” said Blackham.

Investigational trouble

Many payers, carriers, and fiscal intermediaries still consider cardiac imaging procedures investigational procedures, Gregory says.

Without specific CMS guidance or instructions to the contrary, providers and other healthcare professionals should use Category III codes, by CPT definitions, for the purpose of tracking new and emerging technologies, Gregory says.

“In most cases, medical benefits for these services have not yet been defined or validated,” she says. Further, there is no guarantee of reimbursement, she says.

Slicing the pie

David Dowe, MD, a radiologist with AtlantiCare Regional Medical Center in Atlantic City, NJ, sees big financial challenges in cardiac imaging.

“It comes down to splitting the [radiology reimbursement] pie into smaller and smaller pieces for reimbursement money that is not there to begin with,” says Dowe. “It’s an insurance issue. Management is making it hell to get any exam, never mind a cardiac CT.”

There are exceptions that are specifically described in various CMS instructions (e.g., change requests, manuals, or LCDs), and contractors may make individual considerations—in which case the code may be billed and reimbursed according to their fee schedule, says Gregory.

Those payers/carriers who do cover CCTA have specific policies, clinical indications, and criteria to meet to receive reimbursement for the procedure.

Mulaik suggested researching the payment practices of the top 10 payers in your area to determine whether each offers payment for cardiac imaging.

“Don’t rely on rumors about who’s paying for what,” she said. “Do the research.”

“The papers are saying that [cardiac imaging] is extraordinary, that it’s a miracle,” Dowe says.

“Soon it will be that everyone 30 or 40 [years old] or older will have a heart scan as part of their routine physicals,” he says. “But how are we going to pay for that?”

Insider sources

Walter C. Blackham, MS, RCC, president, Specialty Medical Services, Inc., 221 West 8th St., Lorain, OH 44039, 440/245-8010, Ext.10; Walt@spmeds.com.

David Dowe, MD, AtlantiCare Regional Medical Center, 1925 Pacific Ave., Atlantic City, NJ 08401-6713, 609/652-3400.

Stacy Gregory, RCC, CPC, president, Gregory Medical Consulting Services, 2661 N. Pearl St. #364, Tacoma, WA 98407, 253/566-2494; stacy@gregorymedicalconsulting.com.

Diane Millman, Powers Pyles Sutter & Verville, PC, 1875 Eye St., NW, Twelfth Floor, Washington, DC 20006, 202/466-6550; diane.millman@ppsv.com.

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, Coding Strategies, Inc., 5041 Dallas Highway, Suite 606, Powder Springs, GA 30127, 877/6-CODING; melody.mulaik@codingstrategies.com.

Shelley Weiner, MD, FACR, senior medical director, CareCore National, LLC, 169 Myers Corners Road, Wappingers Falls, NY 12590, 845/298-8155; sw@carecorenational.com.

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