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Cardiac CT — Not enough of a good thing

por Sean Ruck, Contributing Editor | March 13, 2020
Cardiology CT X-Ray
From the March 2020 issue of HealthCare Business News magazine

Todd Villines, M.D., is professor of medicine in the Cardiology Division at the University of Virginia Health System. He’s also a strong advocate for the appropriate use of cardiac CT, but he is facing an uphill battle with the relatively new technology as far as heart imaging goes.

“If you compare within the Medicare population, which is probably the best data we have, in 2015 there were 6,232 nuclear tests per 100,000 beneficiaries,” says Villines. “Newer tests, like cardiac CT and cardiac MR, have seen an increase in utilization, but are still vastly less commonly performed. For example, in 2015, there were only 215 cardiac CT studies per 100,000 beneficiaries.”

Cardiac CT’s growth isn’t hampered by lack of research. There are a large number of randomized comparative effectiveness clinical trials that suggest coronary CTA should be the first-line test for symptomatic patients without known prior coronary artery disease. In fact, based on these studies, recent guidelines from the United Kingdom and the European Society of Cardiology state that coronary CTA should be the preferred first-line test in most patients undergoing evaluation for chest pain.

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Instead, cardiac CT is another victim of low reimbursement. “Medicare payment rates for Cardiac CT are markedly lower than any of the other stress imaging modalities,” says Villines. “If you look at the 2020 hospital outpatient fee schedule, payment for coronary CTA is $182 compared to nuclear which is more than $1,200, or stress MR which is over $680. The incentive relative to the work, knowledge, time, and technology is, in my opinion, vastly under-reimbursed.”

The low reimbursement issue seems to be tied, in part, to miscategorization of the procedure and lack of proper documentation regarding the tracking and reporting of costs, work and expertise required. According to Villines, cardiac CT is categorized (at least for Medicare, which often is the benchmark for other payors) as a standard CT or X-ray procedure and not as an advanced cardiovascular imaging test. “It’s lumped in with things like abdominal X-ray and CTs of single organs, but as a test, it is clearly much more challenging to perform and interpret, and takes more time than a standard CT of the brain for instance, where it’s a static, non-moving organ.”

Villines says consideration also isn’t given to the fact that patients have to be given beta blockers and nitroglycerin, with a nurse to administer the medicines and the advanced acquisition techniques and interpretation skills that are required by the clinician as well.

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