Home

  • Home
    • » e-Newsletters

What a difference calcium scoring makes to payers

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2007

Medical necessity guidelines for cardiac computed tomographic angiography (CCTA) procedures vary widely among payers with universal exclusion for asymptomatic patients.

Three particular codes—0144T, 0146T, and 0147T—represent nothing but trouble for hospitals and imaging centers alike, due to perspectives on calcium scoring.

“A couple of carriers say they are not paying for calcium scoring of CCTAs,” says Jim Collins, CPC, ACS-CA, CHCC, president of The Cardiology Coalition in Matthews, NC. “They say it’s tainted fruit.”

The American Medical Association adopted a number of new codes in the 2007 CPT Manual to describe various common scan combinations used for cardiac computed tomography (CCT) and CCTA studies.

As with all Category III (new) codes, the CCTA codes caused some dismay, but the concern with calcium scoring offers its own snags.

That’s because three of the new codes contain some form of calcium scoring within their description, says John Marshall CRA, RCC, RT®, prospective payment coordinator for interventional vascular and radiology at Sarasota (FL) Memorial Healthcare System.

Most payers do not cover coronary calcium scoring, says Marshall. “Medicare and most payers consider calcium scoring (0144T) to be a screening test. However, many payers have applied this rationale to the other CCTA studies because they include minor calcium scoring components within the relatively extensive CCTA procedure. But this is the ultimate moving target. It varies by payer, by region, and seemingly, by day of the week.”

Payers don’t want to reimburse for these screening exams, agrees Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, copresident of Coding Strategies, Inc., in Powder Springs, GA. “A true screening means there are no signs/symptoms, and payers see that as an awfully expensive test for someone with no signs/symptoms of heart disease. They don’t want physicians ordering CT scans of the coronary arteries when the real intent is the calcium scoring,” she says.

Stick to the rules

Calcium scoring helps detect the amount and potential effect of coronary artery disease early.

CCTA is not a covered service for asymptomatic patients. Additionally, three of the new Category III codes contain a calcium scoring component that CMS has classified as a ‘screening exam,’ Marshall says.

Resolve calcium scoring confusion

Despite payers’ hesitancy to come through on reimbursement for calcium scoring, physicians—both cardiologists and radiologists—agree that the scoring element remains critical for “with contrast” scans to adjust images and remove false positive findings, says Collins.

Even though CMS approved calcium scoring as a component of some of the CCTA exams in its draft local coverage determination template, says Marshall, “most payers adopted three of the diagnostic exams but excluded reimbursement of the other two exams because they include a relatively minor calcium quantification [scoring] component.”

The confusion could spur a “big negative effect,” Collins says, particularly if physicians stop performing the scoring portion of the exam, document their work inaccurately, or if coders improperly assign the new codes.

Category III temporary codes help tell the healthcare industry who uses what procedures and why. Inappropriate use of these codes leads to collection of inaccurate data and further billing and coding problems down the line, says Collins.

That’s why it’s vital for everyone to become familiar, not just with the new code definitions, but with the multiple requirements of various payers, says Collins. Examine individual payer newsletters. And when you can’t find the information, call and ask. It may seem overly simplistic, but sometimes the best route is the most direct route.

“A clear understanding of payer guidelines [coverage and coding] is critical to materializing income projections,” Collins says. “If payer guidelines are not favorable, they should be appealed.”

Editor’s note: Learn more about cardiac imaging coding and reimbursement challenges in the recently released HCPro, Inc., publication Cardiac Imaging: Strategies for Appropriate Documentation and Compliant Coding, available at www.hcmarketplace.com/prod-5008.html.

Insider sources

Jim Collins, CPC, ACS-CA, CHCC, president, The Cardiology Coalition, 4812 Hickory Lake Lane, Matthews, NC 28105, 704/845-5142; jim@cardiologycoalition.com.

John Marshall CRA, RCC, RT®, prospective payment coordinator, Sarasota Memorial Healthcare System, 2433 Huntington Avenue, Sarasota, FL 34232, 941/716-5657; John-Marshall@smh.com.

Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, copresident, Coding Strategies, Inc., 5041 Dallas Hwy, Suite 606, Powder Springs, GA 30127, 877/626-3464; Melody.Mulaik@CodingStrategies.com.

Most Popular