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Reimbursement for Cardiac CT/Coronary CTA Services under the Hospital Outpatient Prospective Payment
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The issue

Due to the Deficit Reduction Act of 2005, reimbursement for cardiac computed tomography
(cardiac CT) services provided in the physician office setting is capped at the lower of the
reimbursement amount under the Medicare Physician Fee Schedule (MPFS) or the Hospital
Outpatient Prospective Payment System (HOPPS). The costs accounted for under the MPFS reflectactual direct costs, highlighting the potential under-accounting of supplies, equipment and staff in the hospital outpatient setting. Unfortunately, it is often difficult to capture true costs for performance of cardiac CT and coronary CT angiography (coronary CTA) services in the hospital, as it may be easier for hospital administration to take an average of the scans performed for any purpose based on volume mix, and assign an artificial “cost” to each service, without taking into account the detailed actual costs of the components of a specific Current Procedural Terminology (CPT) code.

How you can help improve reimbursement

In order to obtain fair and appropriate reimbursement for cardiac CT and coronary CTA and to
correct the potential under-valuation of services, it is critically important for hospitals to account for all costs involved in the provision of cardiac CT and coronary CTA services. Specifically, when establishing charges for the cardiac CT and coronary CTA codes that took effect January 1, 2010, hospitals must ensure that they capture all costs typically billed (charged) for all portions of the cardiac CT and coronary CTA services. Hospitals should not simply crosswalk costs/charges without considering the total actual costs of providing each specific CT service. The time and resource demands of quality cardiac CT/CTA make it a very high resource consumer in the CT family. Access to the scanner will be limited if cost captures for cardiac CT services are not adequately represented as compared to other CT CPT cost captures which utilize less time, less specialized equipment , and less support staff in terms of number and educational qualifications.

A thorough accounting of charges will help to ensure that the Centers for Medicare and Medicaid Services (CMS) captures more accurate data upon which to base payment for these services. If charge masters are not updated appropriately, and if the Category I CPT Codes for reporting these services (75571; 75572; 75573; 75574) are not used, hospital outpatient rates will be further jeopardized in future years. It is important to remember that CMS operates within the constraints of a prospective payment system, meaning that CMS uses data collected from the previous two years to set rates for future years. If we do not obtain more accurate data now in the formative years, underreimbursement will continue to be a problem that solidifies and plagues the field.

Please call this problem to the attention of your hospital administration, and request their help to more adequately capture the true costs of performing cardiac CT and coronary CTA services.
Please use the information SCCT has provided in this toolkit to help you in this effort. Each and
every one of us is responsible for taking the steps we can to help secure appropriate access for these resource intense services.


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