Medicare reimbursement is only $175 because it is currently assigned to “APC Level 1 Contrast”. Medicare has categorized CCTA in the same category as general CT services, which is not appropriate for the time and effort which goes into CCTA exams and evaluation.

For the last six years, SCCT and its sister societies, the American College of Cardiology (ACC) and the American College of Radiology (ACR) and respective members have engaged with CMS, Congress and other policymakers to address the declining reimbursement rates for CCTA. These endeavors have consisted of obtaining bi-partisan U.S. House and Senate letters to CMS, personal meetings with CMS leadership, letter-writing, and educating stakeholders. SCCT has maintained that due to the complex nature of CCTA, it belongs in APC 5572, rather than its current APC 5571. SCCT has also published a time-driven activity-based costing study and determined that CCTA’s reimbursement should be in the range of $400.

This is a valid concern. However, this is the first time that CMS has expressed the willingness to change the payment rate for CCTA – in part due to a payer edit that was discovered and relayed to CMS in late 2023. CMS, they found that if facilities had the opportunity to use a cardiology revenue code, then claims would have reflected costs more appropriately, which would have put CCTA codes into a higher APC.

The Ambulatory Payment Classification (APC) is a system used by CMS under the OPPS to determine the reimbursement rates for outpatient services provided by hospitals. It groups similar healthcare services defined by CPT/HCPCS codes together for the purpose of payment, based on the resources required to provide those services.

Maintained by the National Uniform Billing Committee (NUBC), an entity designated by the Health Insurance Portability and Accountability Act (HIPAA), revenue codes describe the type or location of services for the various charge master amounts billed for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. CMS advises hospitals to use the most appropriate revenue code, and expects hospitals to match expenses to revenue via revenue code selection.

Revenue codes are essential for accurate billing and reimbursement. They provide a standardized method to classify services, allowing facilities to submit claims to insurance companies or government payers for payment. In addition, they help insurers verify the medical necessity and payment of claims.

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CMS is reviewing comment letters to identify if there are at least 50% or more facilities that have been billing CCTA codes with a cardiology revenue code OR would be willing to do so, if restrictions are lifted. CMS is asking for information on three specific questions, with respect to your institution:

1. Where are cardiac CT services performed in a hospital? Are cardiac CT services performed in a dedicated cardiology department, radiology department, or some other hospital outpatient department?
2. What factors determine the revenue code assignment for cardiac CT services (i.e., the department in which the service is performed, the type of service that is performed, or some other factor)?
3. What revenue codes are HOPDs reporting for these services in CY 2024? Are HOPDs using the cardiology revenue code on claims for cardiac CT services now that they are no longer restricted from using this revenue code?
   

Yes. At many hospitals, CCTA can use resources across departments. If this is true of your hospital — for example, the current hospital department where the specially trained nurses and other test expenses are currently recorded is a cardiology cost center — then it may be appropriate to use the revenue code 0480. Medicare wants the revenue code to reflect the type of cost center where operating costs reside.

Yes, it is possible. Hospitals do not need to consider where the expense of the CT equipment itself is recorded. Medicare wants the revenue code to reflect the type of cost center where operating costs reside. At many hospitals, CCTA can use resources across departments. If this is true of your hospital — for example, the hospital department where the specially trained nurses and other test expenses are   recorded is a cardiology cost center — then it may be appropriate to use the revenue code 0480.

In this case, you can reference Section 20.5 in Chapter 4 (Part B Hospital) of the CMS Medicare Claims Processing Manual that states: [CMS] “does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals’ assignment of cost vary. Where explicit instructions are not provided, HOPDs should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.” Hospital outpatient facilities must determine the most appropriate cost center and revenue code for the cardiac CT codes.

A revenue code change to cardiology is warranted if the hospital department where the specially trained nurses and other test expenses are recorded is a cardiology cost center. Do not consider where the expense of the CT equipment itself is recorded. If that department is CT, then the revenue code remains 350. If that department is cardiology, then the revenue code should change to 480. The hospital’s and clinicians’ management, protocols, SOPs, etc. of these tests are not changing at all.

Yes! You can help educate other colleagues and administrators on this issue, both at your facility and other institutions.

The deadline to submit comment letters is September 9, 2024.

Submit comments

SCCT currently has a member template letter that can be used to draft a comment letter to CMS. Keep in mind, the most effective letters will be ones that individuals/institutions create and in which they reflect on their own experiences. The template serves as a guide. In addition, there are talking points for clinicians to utilize when speaking with their administrators about comment letters and CCTA reimbursement.

SCCT resources

CMS has stated that if 50% or more of comments indicate CCTA claims are using/could use a cardiology revenue code, it will assign CCTA services to a higher APC (APC 5572 – Level 2 Imaging with Contrast), doubling the payment rate from $175 to $386!