The CCTA Playbook: A Guide to Coding, Reimbursement, and Operations

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A compendium of the business intelligence required to launch a CCTA service

In the United States, unspecified chest pain is the second most common reason for an emergency-department visit. Each year, 5 million to 8 million patients present to the emergency department with chest pain; in 2004, more than 6 million patients presented to US emergency departments with acute chest pain. Of these patients, 4% to 5% have a coronary event that is not properly diagnosed, resulting in an erroneous discharge from the emergency department.

Approximately 40% of elective stress tests will yield false-positive results, but only about 13% of coronary CT angiography (CCTA) exams (see Figures 1 through 4) will have potentially false-positive results. The lower false-positive rate should mean better patient care and cost savings, which should be important to payors.

Figure 1. Patient referred to cardiac CT angiography to rule out obstructive coronary-artery disease was scanned on a Phillips 256-slice Brillance iCT scanner with a low-dose, prospectively gated protocol, demonstrating a nonobstructive mixed (calcified and noncalcified) lesion in the left main artery.

Market Forces

In an acute situation, CCTA could result in cost savings and better patient care by decreasing unnecessary hospital admissions for chest pain. In addition, its use could decrease the incidence of patients being discharged from the hospital if they have true disease.

In a 2007 study,¹ 54 low-risk patients with chest pain who showed no acute ischemia on ECG then underwent CCTA. None of the 46 (85%) patients who were discharged following negative CCTA results experienced any coronary complications within the 30-day follow-up period. These findings support the conclusion that CCTA may safely allow rapid discharge of patients with negative studies.

Given the well-documented sensitivity and specificity of CCTA, why is there hesitation to reimburse for this exam on a uniform national level? For a potentially heavily utilized study, payors want outcomes data before approving reimbursement for new technologies. In the case of imaging, that information can be extremely difficult to obtain. Drugs and medical devices may have measurable effects on patient outcomes, but diagnostic technologies have a less direct connection with patient outcomes because outcomes are more likely to be altered by treatment decisions and patient compliance, among other nonimaging factors.

It is clear, however, that utilization of radiology services is increasing. Diagnostic imaging services paid for under Medicare’s physician fee schedule grew more rapidly than any other type of physician service between 1999 and 2003. During the same period, the average growth in physician services was 22%, but for imaging, it was 45%. Imaging costs are growing at twice the rate of prescription-drug costs, and may continue to grow at an accelerated rate.

These figures make imaging a target for cost cutting, even in areas where imaging has great potential to reduce the total cost of care. In 2007, for example, CMS proposed a restrictive national coverage determination that would have required coverage with evidence development, effectively restricting CCTA to research settings.

In January 2008, six professional societies informed CMS that, if implemented, this policy would have a profoundly negative effect on Medicare beneficiaries by limiting needed access to CCTA for clinically appropriate indications. In response to this and other public commentary, CMS withdrew its proposal in March 2008, allowing Medicare carriers to retain their own local coverage determinations. Until payors become convinced by further research that CCTA replaces other tests (instead of being added to them), a national coverage decision resulting in the creation of category-I CPT® codes for CCTA is unlikely to be made.


There are eight current CPT codes in category III that are applicable to CCTA. They are:

0144T, for CT of the heart without contrast material, including image postprocessing and quantitative evaluation of coronary calcium;

0145T, for cardiac structure and morphology, CT of the heart before and after contrast administration and further sections, including cardiac gating and 3D image postprocessing;

0146T, for CTA of the coronary arteries (including native and anomalous coronaries and bypass grafts) without evaluation of calcium;

0147T, for CTA of the coronary arteries with evaluation of coronary-artery