Why are the Government and Third Party Payors so Scared of CTA? Roseanne R. Wholey 2010

Roseanne R. Wholey, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

Computed Tomographic Angiography/Coronary Computed Tomographic Angiography -CTA is a general phrase used to describe a non-invasive method, using intravenous contrast, to visualize the coronary arteries (or other vessels) using high resolution, high speed CT -CCTA involves the evaluation of the coronary arteries and is a technique for imaging vessels which includes reconstruction post-processing of angiographic images and interpretation

CAD A hot topic for several decades Gold standard - invasive coronary angiography CTA - able to detect early atherosclerotic disease in patients and it is the first modality that can quickly and reliably diagnose and assess the presence of CAD

A sudden resurgence CTA - proven to be beneficial for the treatment of CAD Cardiologists and radiologists - interested in CCTA because it allows them to directly see the coronary arteries

Reimbursement -Benefits are plentiful to the physician and the patient -Less obvious to the payors -Reimbursement issues hinder physicians decisions whether or not to use CCTA

-Differing clinical and reimbursement guidelines exist to guide the use of this method resulting in confusion whether CCTA is reasonably indicated and covered by an individual patient’s payer -Such confusion has slowed the acceptance within the medical community

Medicare’s National Coverage for CT did not specifically address coverage of CCTA. Some local contractors developed Local Coverage Determinations that could either reimburse, restrict or deny coverage

Medicare reimbursement system The majority of CPT codes are Category I codes designated with a five-digit code for which the clinical efficacy is established and documented Category III codes are issued to new technologies to track utilization and have four digits followed by an alphabetic character

Old CCTA Category III emerging technology codes -0146T CCTA w/o quantitative eval of coronary calcium -0147T CCTA w/quantitative eval of coronary calcium -0148T Cardiac structure, morphology, & CCTA w/o quan eval of coronary calcium -0149T Cardiac structure, morphology, & CCTA w/quan eval of coronary calcium

Old Coronary CT Category III Codes 0144T CT heart w/o contrast incl coronary calcium 0145T CT heart w contrast, cardiac gating, 3D image, card structure & morphology 0150T CT heart, card structure & morphology in congenital heart disease 0151T CT heart w contrast, cardiac gating, 3D image, function eval (Lt & Rt vent function, eject fraction, segmental wall motion

To obtain Category I status Procedure is performed across the country at multiple locations Many practitioners perform the procedure Clinical efficacy has been well established and documented in peer review US literature

Medicare Coverage Advisory Committee How the panel rated the technology -Overall diagnostic accuracy -Determine anatomic location of lesions -Determine relevant morphology of lesions -Replace catheter angiography -Incremental benefit before catheter angiography -Incremental benefit after catheter angiography -Can evidence be generalized to Medicare population?

Cardiac CT and CTA Coverage Issues BCBS -The technology must have final approval from the appropriate government bodies -The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes -The technology must improve the net health outcome -The technology must be as beneficial as any established alternatives -The improvement must be attainable outside the investigational settings

Medicare determination 3-12-08 After examining the medical evidence, the Centers for Medicare and Medicaid Services (CMS) has determined that no National Coverage Determination (NCD) is appropriate at this time. Payment decisions should be made by local contractors through a local coverage determination process or case by case adjudication.

CMS spares cardiac CTA Good news - CMS announced that it would not issue a National Coverage Determination (NCD) for CCTA If CMS had issued the determination, it would have drastically limited patient access to CCTA

2010 CTA codes Four new category I codes replace 8 category III codes (0144T thru 0151T)

4 New Category I CT/MRI codes for 2010 75571 CT heart w/o contrast w/quantitative eval of cor calcium 75572 CT heart w/contrast to eval cardiac structure & morphology 75573 CT heart w/contrast for eval cardiac structure/morph for congenital heart disease 75565 Cardiac MRI for velocity flow mapping

But only Category I CCTA code 75574 CTA heart, coronary arteries and bypass grafts (when present) w/contrast, including 3D image postprocessing (including evaluation of cardiac structure & morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

Category I status achieved Success???????? Looks like the 2010 Medicare fee schedule will pay: $363.10 total component 75574 $114.04 professional component 75574-26 $249.06 technical component 75574-TC

Total component reimbursement Reimbursement 2006/2007 – approx $2000 Reimbursement 2008/2009 – approx $1400 Reimbursement 2010 – approx $360

So why are the government and third party payors so scared of CTA? CTA is viewed by leading critics as Expensive Clinically unproven Entails a radiation risk Overused, incentive for financial gain There is no data to suggest there is any reason for anyone asymptomatic to have the procedure performed

Opening the flood gates? There is the belief that CCTA will become a layered test (ex:if a nuclear perfusion study is followed by CCTA and then a diagnostic cath angiography) However, if CCTA is substituted for the nuclear perfusion study or cath, a cost savings can occur as CCTA is the least expensive of the 3 diagnostic tests.

Overutilization? Payors are also concerned that CCTA will be used as a screening test. However, the CCTA Data Registry has evaluated the clinical indications for ordering CCTA studies across the country and the data supports that CCTA studies are being ordered extremely judiciously preventing the study from being used for patient screening.

Another carrier issue Some carriers have denied a majority of CCTA requests because they found a lot of asymptomatic disease putting more patients in cath labs without the discovery of stenoses long enough to warrant revascularization.

A little bad news for the skeptics Now that Medicare has backed down skeptics say it is unlikely that anyone will conduct a major clinical trial to determine if patients who receive CTA’s have better outcomes that those who don’t. And because Medicare has agreed to pay for the test, resistance among other commercial insurers is likely to disappear.

How to bring the payors on board and increase reimbursement? Communicate the facts to the insurance carriers Document outcomes/potential cost savings Continue to appeal for payment Know the facts…

Knowledge of the facts CCTA is a cost effective opportunity for detection of early cardiovascular disease in symptomatic moderate risk patients CCTA has been documented to be the most accurate noninvasive test for the detection of CAD It provides anatomic information about the presence of plaque and narrowing of the coronary arteries before they would become hemodynamically significant

CAD - the leading cause of death in the U.S. CCTA - an important diagnostic technique to help fight heart disease.

What is the future of CCTA? ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????

“It is impossible to make predictions… especially about the future.” Former Vice President Dan Quayle

Now what is the message there Now what is the message there? The message is that there are known “knowns”. There are things we know that we know. There are known unknowns. That is to say there are things that we now know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know. So when we do the best we can and we pull all this information together, and we then say well that’s basically what we see as the situation, that is really only the known knowns and the known unknowns. And each year we discover a few more of those unknown unknowns. Donald Rumsfeld at a NATO Press Conference in Brussels, Belgium 6-6-02