Ethan J. Halpern MD, Presenter: Research grant, Koninklijke Philips Electronics NV Research grant, Lantheus Medical Imaging, Inc Equipment support, Toshiba Corporation

David Fischman, Abstract Co-Author: Nothing to Disclose

Michael Savage MD, Abstract Co-Author: Nothing to Disclose

David C. Levin MD, Abstract Co-Author: Consultant, HealthHelp Board of Directors, Outpatient Imaging Affiliates, LLC

There have been substantial changes in CPT coding and reimbursement for stress testing, coronary CT angiography (cCTA) and conventional coronary angiography between the 2009, 2010 and 2011 Medicare fee schedules. We employed a decision analytic model to evaluate diagnostic accuracy and imaging costs for the diagnosis of coronary artery disease (CAD), and to evaluate how changes in the fee schedule might impact the cost-effectiveness of different work-up strategies.

Our decision model utilizes stress testing (stress ECG, stress Echo, or stress myocardial perfusion scintigraphy (MPS)) and cCTA for evaluation of suspected CAD. All possible combinations of stress tests and cCTA were evaluated. Patients with a positive stress/cCTA evaluation undergo cardiac catheterization. Values of sensitivity and specificity for stress tests and cCTA from the published literature were entered into a decision tree. Costs were evaluated as a function of CAD prevalence based upon Medicare fee schedules from 2009, 2010 and 2011.

The combination of cCTA with any stress study results in a decreased false positive rate (FPR) relative to a stress study alone. FPR is minimized when cCTA is combined with stress echocardiography. Reimbursement for cCTA was reduced each year from 2009-2011, with an overall reduction of 39%.  Reimbursement for other stress studies was reduced by 7-12% over the same two year period. A stress test followed by cCTA results in lower imaging costs as compared to stress testing alone for any disease prevalence below 60-70%. Imaging costs are minimized by a strategy that employs stress ECG followed by cCTA. MPS alone is the most expensive diagnostic option for evaluation of CAD, and has become increasingly more expensive as compared to other options based upon changing reimbursement from 2009-2011.

Changes in CPT coding and fee schedules have reduced the reimbursements for stress tests and cCTA in the 2009 - 2011 Medicare fee schedules.  Work-up strategies that begin with stress ECG or stress Echo and progress to cCTA (if the stress test is positive) represent the least expensive options, and are more cost-effective relative to strategies that utilize MPS.

The evaluation of coronary disease may be optimized by an appropriate combination of stress testing and cCTA to reduce imaging costs and unnecessary cardiac catheterizations.

Halpern, E, Fischman, D, Savage, M, Levin, D, Impact of Coding and Reimbursement Changes in the 2009-2011 Medicare Fee Schedules on Cost-effectiveness of Stress Testing and CT Angiography for Evaluation of Coronary Artery Disease.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11008525.html