Thanks to the College’s efforts, CMS has reclassified CCTA from a lower-reimbursing APC to a higher-reimbursing one.
Juan Carlos Batlle, MD, MBA, FACR, Assistant Professor, Penn Medicine, and Member of the ACR CSC
Guest Columnist
It’s always refreshing to be able to report good news on the reimbursement front. Thanks to ACR’s efforts in collaboration with the Society for Cardiovascular Computed Tomography (SCCT) and the American College of Cardiology (ACC), CMS has reclassified a coronary computed tomography angiography (CCTA) from a lower-reimbursing ambulatory payment classification (APC) to a higher-reimbursing one. In short, this means that for reimbursement purposes, CMS has grouped CCTA with other cardiac chest-pain examinations like SPECT (single-photon emission computerized tomography) nuclear rather than with other contrast-enhanced CT exams. For sites using the Outpatient Prospective Payment System (OPPS), this will double reimbursement for the technical fee (see table 1 below). Note these current $175/$285 payments are technical fee reimbursements, which may explain why hospitals have been reluctant to roll out CCTA programs — reimbursement has been lower than the expense the hospital incurs to perform the test. As an increasingly recognized first-line test for chest-pain evaluation and coronary artery disease, CCTA volume among Medicare beneficiaries has nonetheless grown four times in the last decade, and continued growth is expected.
Table 1. CY 2025 Final Rule Change to CCTA
|
|
|
CY 2024 APC 5571 |
CY 2025 APC 5572 |
% Change |
|
|
|
|
|
|
|
Hospital Outpatient (OPPS) |
|
$175 |
$357 |
+104% |
|
|
|
|
|
|
|
Physician Office (PFS) |
|
$285 |
$318 |
+12% |
|
|
|
|
|
|
One important note: The APC reclassification is provisional. CMS reserves the right to watch claims data to ensure the APC was reclassified correctly. We all can help in this, and here’s how: When we submit claims for examinations to CMS, a revenue code is applied to the claim on the UB-04 form. This revenue code is not a demand for payment, a charge or a price; it reflects how much the hospital spent to produce an exam (a “wholesale cost of goods” if you will). The National Uniform Billing Committee creates revenue codes in groups; for example, if a CCTA is performed, rather than reporting exactly how much that particular exam cost the hospital (scanner time, technologist and nursing labor, disposables cost, etc.), that exam is assigned a revenue code believed to, more or less, reflect the general cost of that kind of exam. See table 56 below from the Federal Register for codes used for cardiac CT angiography examinations.
Table 56: Revenue Codes Reported with CCTA Exams
CPT Codes 75572, 75573, and 75574
| 2022 Revenue center ID |
Description (applicable to CY 2022 claims) | Used in 2024 OPPS (2022 claims) | 2552-96 Primary cost center source for CCR |
| 0320 | Radiology-Diagnostic | Y | 4100 |
| 0321 | Radiology-Diagnostic: Angiocardiography | Y | 3030 |
| 0329 | Radiology- Diagnostic: Other | Y | 4100 |
| 0350 | CT Scan | Y | 3230 |
| 0351 | CT Scan: Head | Y | 3230 |
| 0352 | CT Scan: Body | Y | 3230 |
| 0359 | CT Scan: Other CT scans | Y | 3230 |
The hospital accounting department can then choose which revenue code to apply (because the infrastructure of a hospital and therefore its expenses can vary from hospital to hospital), and many choose code 0350 “CT Scan.” That seems like common sense, but it dramatically underreports the expense to produce a CCTA because it drops a relatively small number of high-cost-to-produce CCTAs into an ocean of not-as-high-cost-to-produce CT scans (e.g., chest CT, head CT). A multicenter study showed that even in hospital centers that experienced high volumes of CCTAs, it cost the hospitals three to four times more to produce a CCTA compared to a contrast-enhanced chest CT.
A second issue with the CT revenue code is that many hospitals continue to use square footage of the CT department to report costs (which then are used to calculate the Cost to Charge Ratio (CCR) for that revenue code), rather than the actual direct cost of the CT scanner. This would lead to the CT scanner cost going into the hospital-wide expense “bin” and then divided equally into all departments (and accordingly diluted into hospital-wide square-footage expenses). For both CT and MRI, department-specific capital-intensive equipment and maintenance costs would drive much higher reported expenses than a square-footage calculation, but hospitals have lagged in making these changes, which has kept CT’s CCR artifactually and inappropriately low. That low CCR is applied to the 0350 revenue code, which then goes into CMS’s claims data, which then informs how APCs are reimbursed.
Thanks to advocacy efforts and discussions with the CMS chief transformation officer, the inability to use higher-expense revenue codes has recently been resolved. In their January 2024 OPPS update, CMS reported, “We recently identified an outdated return-to-provider (RTP) HCPCS-to-revenue code edit that limited certain claims submissions to specific revenue codes for Current Procedural Terminology (CPT®) codes 75572, 75573 and 75574. We had RTP-ed these claims to the providers for resubmission. We removed this outdated edit, so, when appropriate, you may bill these codes with any appropriate revenue code.” An “edit” is CMS’s euphemism for “red flag detector” — when a hospital’s claim goes to CMS and CMS believes the wrong coding has been used, an “edit” related to those radiology exams flags the claim to be returned to the provider. Often this happens within the hospital’s own billing software (e.g., “Billing Editor”). This particular CMS edit caused many CCTAs with revenue codes deemed inappropriate to be rejected. Now, hospitals will have leeway to use different revenue codes, e.g., cardiology revenue code 0480 or radiology code 0320, both of which would report higher expenses to CMS. Revenue code 040x (e.g., 0400 Other Imaging Services — General or 0409 — Other) may also be considered. A hospital’s accounting department can help practitioners confirm that the new revenue code being considered does represent that hospital’s actual cost in performing CCTA. Perhaps a hospital is so efficient at performing CCTA that it wishes to continue reporting CCTA cost within a CT department revenue code, and that is reasonable also.
These were hard-fought changes to the APC reimbursement group. To help keep them, please discuss the changes with your hospital or facility accounting department and help them understand the vital importance of reporting cost accurately by applying the revenue code that best reflects cost. Please do not hesitate to contact ACR if you receive rejections based on claims edits.
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