Update on Cardiac CT and Coronary CTA Coding


With the rapid growth of cardiac computed tomography (CCT) and coronary computed tomographic angiography (CCTA) throughout the country, there have been many questions raised on when Category I CPT codes would be implemented to describe these procedures. This article will address the efforts being made by the American College of Radiology (ACR) and American College of Cardiology (ACC) to establish the appropriate code set to describe these procedures.

The ACR and ACC worked closely through the CPT code application process and established eight Category III codes (0144T-0151T) describing CCT and CCTA. Because of concerns by payers that numerous individual codes might be necessary for each encounter to clearly describe these often concurrent services, it was agreed that the creation of several new codes describing common combinations and permutations would allow, in most cases, for a single code to describe whatever combination of services was performed.1 The use of CPT Category III codes 0144T-0151T will provide the specialty societies with important utilization data needed to request the appropriate CPT Category I codes. This also will aid in the proper description and valuation of these studies.

Once the typical CCT and CCTA procedures are identified and it is established that the procedures are performed in a uniform and repeatable manner with significant frequency, all-inclusive Category I procedure codes will be requested.

When will Category I codes be established to describe CCT and CCTA?

The CPT Editorial Panel meets three times per coding cycle in June, October and February. For example, February 2007 will be the last panel meeting for the 2008 CPT code cycle. The June 2007 meeting will be the first panel meeting of the 2009 CPT code cycle.2]

Category I codes to describe CCT and CCTA will not be available before January 1, 2009.

The ACR and ACC CPT advisors, as well as economics and clinical experts in the field, have been tracking the CCT and CCTA literature. Both societies agree that the timing is not right to convert the eight Category III codes (implemented 1/1/06) to a Category I code status and will wait until the clinical trials currently in progress begin to report results in the literature. It is agreed, by clinical experts from both societies, that the scientific evidence necessary to show the clinical efficacy and cost-effectiveness of the technology is not available to support the creation of Category I codes for the 2008 CPT cycle. Because payers have concerns that these cardiac imaging codes will generate claims for another procedure, in addition to what is currently available, the societies will need to provide robust data to counter the argument that this is not just an additional payment. Societies will need to show CCT and CCTA will be a substitute for other tests.

To be considered for Category I code status, a procedure or service should have FDA approval, if necessary, be performed nationally, and have proven clinical efficacy (scientific evidence) supported in US peer-reviewed journals. In addition, the ACR and ACC will need to demonstrate that the procedures will be performed in a consistent fashion. When procedures reach a level of stability in their performance, they have an impact on clinical decision making and have a defined place in the medical armamentarium. This stability will signal to the CPT Editorial Panel that new codes, if developed, will be reasonably durable. This also will help in the proper assignment of a code descriptor and valuation of the codes when reviewed by the Relative Value Update Committee (RUC).

How are Category I CPT Codes Valued?

Category I CPT codes are valued by the RUC. The RUC uses survey data obtained by the specialty societies indicating multiple factors involving physician work and practice expense. The RUC then recommends a value to the Centers for Medicare & Medicaid Services who makes the final determination. Before submitting a code to the RUC, it is important to have a Category I code that reflects what typically occurs in clinical practice. Having the appropriate work description will aid in properly valuing the code. Both societies feel that if a code were to be prematurely approved at this time and reviewed by the RUC, the reimbursement would not be accurate, based on the data that is currently available. Therefore, the ACR and ACC have agreed to look at how the Category III codes are being used over the next year. This will allow time to determine the appropriate type and number of codes to be established.

Reporting of the current CCT and CCTA Category III codes will make it possible for the specialty societies to obtain the necessary utilization data needed to determine the types of studies being performed. It is then that a code set to describe the typical clinical scenario can be valued. At this time, there is little information from the carriers and third party payers regarding the use of codes 0144T-0151T, as these codes were implemented in January 2006.

Are CCT and CCTA studies reimbursed when a Category III code is used?

Because Category III codes are not valued by the RUC, payment for CCT and CCTA is at the discretion of the individual payers. There are a number of payers who have reimbursement policies in place for the 0144T-0151T Category III codes. Click here for a listing of payment policies established at this time.

What are societies currently doing?

ACR and ACC are continuing to ensure that necessary data is obtained to move forward with a CPT Category I code application in 2009.

Both societies are:

  1. monitoring the progress of the clinical trials being performed and obtaining outcomes data to see what place CCT and CCTA have in the armamentarium and how it affects clinical decision making;
  2. tapping into claims and utilization data by working through the Carrier Advisory Committee networks to look at consistency in performance and determining the appropriate code structure needed to define CCT and CCTA; and
  3. working with guidelines and standards groups to see how work is complementary.

Clinical trials studies, such as SMART, sponsored by the National Institutes of Health, are currently underway to validate CCT and CCTA. These trials will address the efficacy of the procedures and the effects on management decision making. Once the trials data show that the treatment course of a specified number of patients is impacted by the use of this technology and is not an additional study in a cascade of studies being performed, a coding proposal will be submitted. Outcomes data from these trials is not yet available, but it is anticipated that scientific evidence will be available next year.

Summary:

The CPT Editorial Panel is comprised of 17 members. Of these, 11 are physicians nominated by the AMA; one physician each nominated from the Blue Cross and Blue Shield Association, the Health Insurance Association of America, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS), and the cochair and a representative of the Health Care Professionals Advisory Committee. The AMA's board of trustees appoints the Panel members.

Based on the initial Category III code application presentation, both specialty societies anticipate a high level of scrutiny at the CPT Editorial Panel when a request is finally made to convert the Category III codes (0144T-0151T) to a Category I status. Therefore, the ACR and ACC are continuing to work to ensure the scientific evidence is available to support this conversion.

The ACR and ACC are continuing to collect data to show that CCT and CCTA procedures effect decision making and have a defined place in the cardiac armamentarium. Once the literature supports these procedures the societies will bring forth a proposal, most likely next year, so that a group of well-constructed and durable codes will be available for use in 2009.

Until then, the Category III codes must be used to describe CCT and CCTA procedures (unless otherwise required by a payer) to provide the necessary utilization data.

The ACR and ACC recently worked together to revise the cardiac MRI codes to create a code set that describes not only an anatomic test, but a code set that accurately describes physiologic evaluation. The new code set that will describe functional and morphologic assessment will be addressed at the October CPT Editorial Panel meeting.

Click here for a listing of Medicare Local Coverage Determinations (LCD), model LCDs, and third-party payer coverage policies to see if CCT and CCTA are covered in your area.

1AMA/ACR Clinical Examples in Radiology, Vol 1, Bulletin 2, 2005, Cardiac Computed Tomography and Computed Tomographic Angiography Coding.

2AMA, CPT Process. How a Code Becomes a Code, http://www.ama-assn.org/ama/pub/category/3882.html.