CMS Proposes Cuts to Cardiac CT Reimbursement, Provoking SCCT Ire

Proposed changes to the Centers for Medicare & Medicaid Services (CMS) billing codes associated with cardiac computed tomography for 2020 would drop reimbursement rates by 10-30% for three main CT angiography codes, both in hospitals and at stand-alone clinics.

The announcement by CMS late last month has imagers crying foul, saying the cuts will limit the use of CT in circumstances where it provides the most benefit, while others are questioning the accuracy of the data the agency relied on to set its proposed rates.

Dustin Thomas, MD (Parkview Regional Medical Center, Fort Wayne, IN), who serves as the chair of the advocacy committee for the Society of Cardiovascular Computed Tomography (SCCT), says the proposed cuts go a step too far. “We've seen a 1-2% cut over the past couple of years per year, which is fairly in line with many other imaging modalities,” he told TCTMD. “But certainly this year's cut was pretty tremendous.”

The timing is conspicuous, since guideline changes are anticipated later this year that would increase support for the use of cardiac CT for the initial assessment and diagnosis of patients with suspected stable coronary artery disease. There’s also been a major uptake in the use of cardiac CT in the context of structural heart interventions. At the same time, cardiac CT procedures have long been the target of critics who say there’s too much potential for overuse, that the evidence base is shaky, and that CT tests will ultimately lead to more downstream procedures, thereby driving up costs—all charges that CT advocates have resolutely rejected.

Thomas asserted that a balance can be found. “What we're trying to do as a society is not so much to drive the rate up to some astronomic level where obviously everyone is going to be making out like gangbusters doing cardiac CT all day long, but ultimately to take it up to a level where sites that have expertise and interest in doing this, and [are] practicing in accordance with recent data and soon-to-be-published guidelines, can do it in a way that is both in the best interest of patients and keeping patients in the center of care but also allows them to continue to keep the lights on,” Thomas said.

The SCCT is advising its members and all who use cardiac CT to push back against the proposed changes. The CMS proposal is open for public comment through September 27, 2019.

What Codes are Affected?

CMS posted projected 2020 billing rates for both its Medicare Physician Fee Schedule (MPFS), which includes private practice physicians, standalone clinics, and foundations, and Hospital Outpatient Prospective Payment System (OPPS), which covers all hospital-based procedures. The three codes facing the largest proposed rate reductions are:

• 75572: Heart CT with contrast for evaluation of cardiac structure and morphology
• 75573: Heart CT with contrast for evaluation of cardiac structure and morphology in the setting of congenital heart disease
• 75574: CT angiography of the heart, coronary arteries, and bypass grafts with contrast
   

Proposed MPFS Changes

Proposed OPPS Changes

Notably, the 75571 code for a heart CT without contrast for the quantitative evaluation of coronary calcium will see 1.3% and 30.9% increases for MPFS and OPPS, respectively, in 2020 compared with 2018. Also, while CT-derived fractional flow reserve (0503T) has not been reimbursed under MPFS and will continue not to be, with the proposed changes, it will receive 48.2% less reimbursement under OPPS in 2020 ($750.50) than it did in 2018 ($1450.50).

Why the Cuts?

Thomas said there are several potential reasons why CMS is proposing these cuts and that the SCCT is currently analyzing the available data to understand the full picture. However, he guessed that changes in how institutions report their CT costs to CMS in recent years might be having unintended consequences.

“It used to be that CMS allowed you to estimate cost for your scanner based on the square footage of the room [that] the scanner was in,” he said. “Within the last 5 or 6 years, they changed the rules to require hospital systems to report direct costs associated with their scanner room and scanner maintenance. Many centers have not made changes to how they report their cost, and so we're wondering if some of the significant reduction we're seeing is that those sites are now being brought on and being used toward rate setting.”

The conversation about the underreporting of costs associated with cardiac CT is not a new one. “We have sites across the country who are charging as little as $28 for coronary CT angiography, which just isn't compatible with the cost of the test,” Thomas said. “That charge rate wouldn't even cover the salary for the tech who sits there and runs the test. So there's some pretty wonky charges out there right now that are really kind of inexplicable but are unfortunately being used toward setting the rate that everybody has to work under.”

Because coronary CT still remains a low-volume test at many centers around the country, he noted that there is likely “a disconnect between the C-suites and some of the administrative personnel in each hospital system [and] experts in cardiology departments.” It’s possible also that institutions aren’t properly accounting for the individual cost of a cardiac CT because they are “lumping it in with other single-organ-system CT angiography studies,” Thomas added.

“It really just boils down to how much effort various hospital systems have put in to evaluate and to assess cost associated with each specific individual [Current Procedural Terminology] (CPT) code in their institution, and certainly there's thousands of CPT codes for various procedures,” he continued. “So you certainly can see where hospital systems may choose to allocate their resources to more higher-volume, potentially higher-reimbursement codes and making sure that they're capturing those charges correctly, but obviously in this particular case, just based on the way that CMS sets its rates, it's obviously hurting centers across the country.”

Thomas’ advice for practitioners was clear. “It's vitally important to know what your hospital system charges for coronary CT angiography and what it reports as its cost associated with that procedure,” he urged. “And if you find that your hospital is charging an inappropriately low number or not appropriately capturing the charges associated with performing the test, then work with your administrators to fix that. [That's] not only going to help you to appropriately justify your utilization of resources and your personnel to perform it in your own institution, but [also] it allows the costs associated with the test to be more accurately reflected across the country when it comes to taking care of Medicare patients.”