Setting Up a CCTA Service
Your hospital just installed a new multidetector CT (MDCT) scanner of 64 slices or more, and your emergency-department physicians are clamoring for a 24/7 coronary CT angiography (CCTA) service; now what?
David Dowe, MD
According to David Dowe, MD, a private-practice radiologist with Atlantic Medical Imaging, Atlantic City, New Jersey, and a passionate teacher and advocate of the study, a practice interested in launching a CCTA service must focus on three things: image quality/diagnostic superiority, service, and marketing. On May 3, Dowe (who describes the study as beautiful, quick, and easy to administer) told radiologists at the annual American Roentgen Ray Society meeting in San Diego, California, that CCTA’s time has come, and not just in the emergency department. Dowe asserts that the literature is replete with comparisons of CCTA with catheterization and stress tests in asymptomatic and symptomatic patients. Universally, he says, that work shows not only that CCTA is superior to stress testing as a first-line test, but also that it saves money, no matter where it is used. “Why should half of US catheterizations show 50% or less stenosis?” Dowe asks. “There should never be another elective, negative diagnostic catheterization here. We have CCTA available in all 50 states.” Diagnostic Superiority Image quality is a function of proper patient selection and preparation (and excellent equipment), Dowe says. The minimum equipment required is 64-detector MDCT system with prospective gating capabilities. Many courses are available covering the correct CT-imaging variables. Proper patient selection: There are few patients for whom Dowe will not do CCTA. His list of absolute contraindications consists of five circumstances: uncontrolled atrial fibrillation, bigeminy, trigeminy, or high-grade heart block; severe, uncontrolled asthma; renal insufficiency; a prior allergic reaction to contrast while on steroids; and patient weight exceeding the 500-pound limit of his CT table. There are some patients for whom CCTA will fail, Dowe says, but educating your schedulers on proper patient selection can minimize those events and save time. “Don’t be your own worst enemy; educate your schedulers,” he advises. Patient preparation: Dowe advocates getting the preparatory packet to the patient in advance. The packet includes all of the necessary cardiac/medical-history forms, a brief description of what to expect during CCTA, and a beta-blocker. Service In the interest of delivering excellent service, Dowe has two ways to administer the beta-blocker. In the first method, a day in advance, at one of Atlantic Medical Imaging’s sites, the patient’s resting heart rate is checked to make sure that it is above 60 beats per minute (bpm); if it’s lower, a beta-blocker is not needed (and could be harmful, Dowe says). The alternative is to ask the patient to arrive an hour early for the exam (an option recommended for patients already on beta-blockers). The drug is then given only if necessary. Dowe never faxes a prescription to a patient, nor does he ask the ordering physician to take care of it. “Those are not friendly possibilities,” he says. Before the exam, patients’ vital signs are obtained in a quiet room, and if their heart rates are greater than 72 bpm during breath holding, they are remedicated. Dowe uses oral beta-blockers exclusively, eliminating the need for preinjection/postinjection monitoring by a nurse and reducing the drug’s postexam effects. IV access is obtained, in another room, before the exam, and no one gets on the CT table without prior verification that his or her heart rate is where it needs to be. Dowe describes the exam itself as very brief, taking 10 minutes or less. He shows patients their images before they leave the building (a key service element in his practice). He acknowledges that this is where the radiologist interested in launching a CCTA service could run into trouble. “Your partners may not support that activity; they may say, ‘What are you doing? We don’t bill for that visit.’” Dowe suggests that early in the endeavor, when processing takes extra time, patients should come back later in the day. Whether immediate or postponed, that patient contact is not optional, Dowe notes. “You are not going to be involved in CCTA if you are as invisible as you are in a routine CT. There are too many other people who want to do this exam for you,” he says. After the patient leaves, the interpretation is dictated, the technologist creates a 3D volume-rendered image for the referrer, and the report is mailed. Marketing Dowe identifies five primary referral sources for building a CCTA practice: cardiologists, primary-care physicians, internists, surgeons and anesthesiologists, and nurse practitioners and physician assistants. Your mix will vary greatly, depending on your market location. Cardiologists inclined to order CCTA probably will do so after a stress test and before a diagnostic catheterization, and there is a strong likelihood that such a study will be precertified by an insurer. “They are slowly starting to learn that they can prevent a lot of negative catheterizations,” Dowe notes. Primary-care physicians and internists are another potential source of referrals, but they run into precertification difficulties in New Jersey, Dowe says. They do order a significant number of CCTAs under plans that don’t require precertification. Preoperative clearance is an active source of referrals: Surgeons, anesthesiologists, nurse practitioners, and physician assistants are all potential referrers for CCTA. “Patients in their 70s and older who are getting total hip and total knee replacements are going to come to you for CCTA. They also get echocardiograms,” Dowe reports, “but CCTA is the driver in preoperative clearance.” Dowe reports that there now are four CPT® codes (see table) used for CCTA: 75571, basically the calcium-scoring code that replaces the 0114T code; 72272, used for cardiac structure and morphology, left atrium, and pulmonary venous mapping; 75573, used for cardiac structure and morphology in the presence of congenital heart disease; and 75574 (the code most commonly used for CCTA), which replaces the 0146-0149T codes. For a TRO cardiac CT, also bill 72175, chest CTA. Dowe emphasizes that there is no ICD-9 code for the work-up of an asymptomatic patient with risk factors; he also warns providers never to bill for calcium scoring (75572) in addition to 75574, as this will result in immediate claim rejection. Radiology’s Trump Card If anything works in favor of the radiologist performing CCTA, it is the emergency department. This is a bona fide opportunity, though a somewhat onerous one, due to its around-the-clock service requirements. “Cardiologists are not set up to offer CCTA 24/7,” Dowe notes. “In general, good luck finding a radiology group that wants to read CCTA 24/7. It’s a very difficult proposition.”
Table. CPT® Codes for Cardiac CT and Coronary CT Angiography
Nonetheless, there are benefits for all stakeholders. For hospitals, the advantages include decreased lengths of stay, decreased costs of care, and tremendous throughput enhancement in the emergency department. “What they don’t want is a nonpaying patient sitting in a bed for eight hours, waiting to have a stress test the next day,” Dowe says. “They want to turn over those beds.” Both hospitals and payors are interested in decreasing liability risks in the emergency department. “The biggest cause of malpractice in the emergency department is management of chest pain,” Dowe notes. “In the future, there may be better contracts (or novel contracts) from-third-party payors that insist upon having CCTA 24/7. It may be futuristic right now, but I think that day will come.” Patients also benefit from more accurate triage, from spending less time in the emergency department, and from getting into the hands of the correct specialist sooner. Dowe says that only about a quarter of emergency-department chest-pain patients have coronary-artery disease, with the overwhelming majority of patients suffering from gastrointestinal disorders instead. Dowe urges forging ahead, despite resistance, because radiologists are the ideal physicians to do CCTA. “You can read the whole exam, you understand CT, and you understand radiation protection,” he says. “I will tell you this: I am seeing it in New Jersey, with precertification companies forbidding specialists from having high-tech CT, MRI, and PET in their offices. It is slowly coming our way.”