Adding a CCTA Program: Economic Benefits of Outsourcing

Adding a coronary CT angiography (CCTA) program to your emergency department can help save hundreds of thousands of dollars a year by reducing unnecessary admissions and mitigating the medicolegal expenses resulting from misdiagnoses. The upfront equipment costs are daunting, however, as are ongoing expenses in the form of both technologist salaries and software service contracts. In a recent webinar, William Shea, MD, vice president of 3D imaging and cardiac imaging for NightHawk Radiology Services LLC, Coeur d'Alene, Idaho, reviewed some of the pitfalls of setting up a CCTA program. Is outsourcing the best solution?

"Even the largest institutions don't have the technical or professional staff to offer subspecialization 24 hours a day, seven days a week, 365 days a year." —William Shea, MD

Coronary-artery disease is the number-one killer in the United States. Approximately 6 million to 8 million emergency-department visits annually are for chest pain, according to Shea. Only 10% of these visits are made by patients who are having heart attacks, but of the remaining 90%, 10% are sent home in error and will later experience myocardial infarction (MI). For these patients, the mortality rate of MI is three times higher than for patients whose problems were accurately diagnosed in the emergency department. That's why 30% to 40% of emergency departments’ medicolegal expenses involve misdiagnosis of coronary-artery disease. Establishing a CCTA program benefits all players along the continuum of care, Shea says. Patients are diagnosed more accurately and more quickly, emergency-department physicians face less liability exposure and benefit from more rapid turnaround, radiologists get decent technical reimbursement, and hospital administrators see fewer unnecessary admissions, resulting in cost savings. Getting Started To initiate your CCTA program, Shea says, you'll need properly trained physicians and technologists. Both the ACR and the American College of Cardiology (ACC) offer CCTA accreditation for cardiologists and radiologists. For level-2 ACC accreditation, 150 supervised cases and 50 hours of CME are required; the ACR's requirements are somewhat less stringent, at 50 supervised cases and 30 hours of CME. "There is a greater requirement from the ACC, but that makes sense, as cardiologists haven't been through the residency program," Shea explains. There is still no formal training program for 3D technologists, but workstation training is offered by vendors and by teaching institutions such as Johns Hopkins. Next, a hospital needs the right equipment, namely a 64-slice CT unit and the workstation and software needed to process the images. "The equipment requirements are great to establish this service," Shea notes, "but if you've got the equipment, you want to use it." Each 64-slice CT vendor offers a dedicated workstation, and three independent vendors offer them as well, at around $125,000 for the hardware. The software is a separate expense, costing around $75,000 for each application, including volume rendering and maximum-intensity projections. In addition, a service contract is necessary for upgrades and maintenance; Shea estimates this expense at around $50,000 annually. "All of the workstations are excellent, but very expensive and difficult to maintain," he says. Building a Referral Base When Shea helped build the CCTA program for Methodist Hospital, San Antonio, he knew that the first step was reaching out to the appropriate medical staff at the hospital. "Target the early adopters," he advises. "We targeted the vascular surgeons and the pediatric cardiovascular surgeons." Shea and his team reached out to the referral base by hosting conferences and open houses, giving clinicians the opportunity to see the images that could be generated and how the workstations operate. Ease of scheduling is also a crucial factor in initiating any new program; "Schedulers should know all of the requirements, including beta blockers, and all of the rules, such as no caffeine," Shea notes. Sample studies can also be a useful tool for both physicians and their staffs. Shea cites the ROMICAT study¹ from Harvard Medical School, which found a 100% negative predictive value for patients triaged using cardiac CT. "When the cardiac CT is normal, the patient is normal and not having an adverse event," he says. "We can use these studies to educate our medical staff." Other useful reports include the CorE 64² and ACCURACY³ studies, both of which confirmed the high negative predictive value of cardiac CT for patients presenting with acute chest pain. The Reimbursement Piece Because there are currently no CPT® codes for cardiac CT, two tertiary codes (or three, depending on the payor), ranging from 0144T to 0151T, must be combined. "For instance, if one includes a calcium score as part of the study, performs retrospective gating, and does left-ventricular analysis, we could then code 0149T and 0151T for functional evaluation," Shea explains. "That would provide reimbursement, at the average CMS rate for the technical component, of around $500." The professional component would add 20% to 25%. "None of the commercial payors are required to cover CCTA, but most follow the local Medicare determination," Shea says. To determine your local coverage determination, find out who your intermediary is; then, with your provider number ready, use either its Web site or its customer-service line. Some major commercial payors have published a national statement on cardiac CT. For instance, Aetna's policy, posted on its Web site, states that the payor "considers cardiac computed tomography angiography of the coronary arteries using 64 slices or greater medically necessary for the following indications: evaluation of persons with chest pain presenting to the emergency department when an imaging stress test or coronary angiogram are being deferred as the initial imaging study." In other words, "All patients getting cardiac CT in the emergency department will be reimbursed by most payors," Shea says. Benefits of Outsourcing Even if an institution has the equipment for CCTA in place, the benefits of outsourcing are myriad. Because CT angiography reconstruction is not automated, it takes a technologist around 40 minutes to perform the reconstruction. If that technologist could be performing four CT scans per hour, then the lost revenue per reconstructed CCTA amounts to around $700; the lost revenue annually, on one CCTA per day, is $175,000. Adding a dedicated 3D technologist might not be the best solution: Paying one technologist to perform 3D reconstructions for one shift would cost around $500 per day (with salary, benefits, and training), and to have a round-the-clock staff of dedicated 3D technologists could cost as much as $2,000 per day. "Outsourcing keeps your technologists busy getting scans done," Shea says. How does outsourcing work? NightHawk acquires the CCTA from the hospital modality, moving it directly to its PACS or IT network. "From there, the data are sent to our lab in Austin, where the processing is performed, and the information is sent back to your PACS, our physicians, your referring physicians, and your emergency department doctors," Shea says. After acquiring the dataset, NightHawk assesses the raw data to see which portion of the cardiac interval is best to study, drops and edits center lines, creates morphology and down-the-pipe views of the thoracic aorta, and creates volume-rendered scenes to send to NightHawk's thin client. Clinicians can then access the material through the thin client, using their PCs like workstations. "If you outsource, you can save both the time and the cost of training physicians and technologists, eliminate workstation costs, and eliminate the service contract," Shea says. "Even the largest institutions don't have the technical or professional staff to offer subspecialization 24 hours a day, seven days a week, 365 days a year. Outsourcing increases capacity and improves in-house workflow."