When the U.S. Centers for Medicare and Medicaid Services (CMS) doubled the reimbursement for coronary CT angiography (CCTA) beginning in 2025, the higher payment incentive opened the door for wider acceptance and adoption of 3D imaging in cardiac and diagnostic programs.
The CMS had long said evidence demonstrated that CCTA could reliably rule out the presence of significant coronary artery disease (CAD) in certain patients and could reliably achieve a high degree of diagnostic accuracy and technical performance necessary to replace conventional angiography.
With radiologists, cardiologists, CT and 3D technologists, and nurses essential to a cardiac CCTA imaging program, hospital and practice administrators are learning what the CMS's 2025 payment position means for their operations.
When the U.S. Centers for Medicare and Medicaid Services (CMS) doubled the reimbursement for coronary CT angiography (CCTA) beginning in 2025, the higher payment incentive opened the door for wider acceptance and adoption of 3D imaging in cardiac and diagnostic programs.
The CMS had long said evidence demonstrated that CCTA could reliably rule out the presence of significant coronary artery disease (CAD) in certain patients and could reliably achieve a high degree of diagnostic accuracy and technical performance necessary to replace conventional angiography.
With radiologists, cardiologists, CT and 3D technologists, and nurses essential to a cardiac CCTA imaging program, hospital and practice administrators are learning what the CMS's 2025 payment position means for their operations.
Society of Cardiovascular and Computed Tomography (SCCT) health policy and practice committee leaders were among those anticipating the reclassification of CCTA into a higher ambulatory payment classification (APC). In late 2024, the CMS increased the payment rate for CCTA from $175 to $357.13, as part of the calendar year 2025 Hospital Outpatient Prospective Payment System (HOPPS) final rule.
Hospitals make up just over half of CT sites in the U.S. and perform 82% of CT procedures, while nonhospital facilities make up 45% of sites and perform 18% of CT procedures, according to "CT Outlook," one of two new IMV* Market Outlook reports that estimated the current state of a projected universe of 7,653 sites (4,968 hospitals and 2,685 independent imaging centers).
At the same time, IMV's other report, "Cardiology in Diagnostic Imaging Market Outlook," supported the assertion that hospital outpatient cardiac CT imaging procedures weigh most heavily in overall imaging volumes. In addition, open-ended survey responses suggested that AI in 3D rendering, CT postprocessing, and angio CT are currently being used in clinical diagnostics.
IMV: 2024 Cardiology in Diagnostic Imaging Market Outlook
The data points are highly relevant in relation to the CMS's current stance on CCTA reimbursement. For AuntMinnie.com, radiologist Michael Coords, MD, regulatory task force lead for the SCCT Health Policy and Practice Committee, explained that the reimbursement increase for 2025 has the biggest impact on hospital outpatient centers and on their technical component payment.
Payment clarification
"The headlines you see are for the technical component doubling for hospital outpatient centers," Coords explained, "that is not for what predominantly my group is which is a true outpatient setting billing under the [Medicare] Physician Fee Schedule. Coords is also medical director of cardiac imaging at RadNet and is based in Southern California.
Michael Coords, MD.
"For many years, and it continues in some settings, coronary CTA was underreimbursed,” Coords continued. "Compared to a CTA of the chest, there are additional resources that are needed, such as faster CT scanners, medications, special postprocessing software, and additional support staff, which means more expenses for the practice performing it."
In addition, coronary CTA was previously often billed under a radiology revenue code due to an outdated coding edit restriction that prevented the often more appropriate cardiology revenue code from being used. However, Coords said in many settings there are shared resources between radiology and cardiology, as well as additional expenses for the technical component.
"[The CMS] changed [CCTA] to the higher APC category, which better aligns with the resources needed to perform this life-saving exam," Coords said. "This is very important to get adequate reimbursement for hospitals in the outpatient setting, but this is not doubling the global reimbursement in the outpatient setting for the Physician Fee Schedule. That went up by 12% but that did not double."
There is a large benefit in showing a patient their coronary artery disease with CCTA, not just a lab value, according to Coords, who also pointed to benefits demonstrated during the SCOT-HEART (Scottish COmputed Tomography of the Heart) 10-year trial. Data showed a decrease in nonfatal myocardial infarction and with higher preventive medication use among the people who underwent CCTA, Coords said.
"Physicians are realizing they can evaluate the coronary arteries in the outpatient setting and catch coronary artery disease (CAD) before a patient has a major cardiac event. Doctors and patients are starting to realize they often need to be more aggressive with management and for many patients just having a 'normal' cholesterol in range is not enough especially if they have other risk factors." — Radiologist Michael Coords, MD, on the impact of wider use of CCTA due to a more favorable reimbursement rate in hospital outpatient centers.
Coding confusion
Today, most of the conversation is related to Current Procedural Terminology (CPT) code 75574 which is coronary CTA. Cardiac CTA is another CPT code, 75572. These two codes are tailored to evaluate different anatomic structures.
A coronary CTA is protocoled in a way to optimize the evaluation of the coronary arteries but due to the nature of how a CT scan is performed other anatomic structures are also in the field of view. The radiologist will review all anatomy in the field of view which also includes noncoronary structures such as the heart, lungs, bones, and upper abdomen.
All three codes, according to Addendum B updated January 2, 2025, have been set at $357.13. If groups do not bill using the cardiology revenue code to justify APC 5572 then it may revert back to lower reimbursement.
"From our own client's perspective, these studies are usually a split read between radiology and cardiology," Sandy Coffta of Healthcare Administrative Partners (HAP) told AuntMinnie. Coffta, who is vice president of client services for HAP, said the services often require a special billing arrangement.
At Sharp Healthcare in San Diego, CA, senior radiologist Eric Goodman, MD, told AuntMinnie.com that his large, multispecialty medical group concentrates on coronary CTA in its mix of an average of 600 to 700 cardiac CT exams per year and other exams. The practice installed its first cardiac CT scanner in 2007.
"We've been preparing for this for quite a while," Goodman said, adding that his practice plans to double access to the coronary CTA procedure from 10 cases to 20 cases per week by April.
"Newer generation cardiac CTs provide a much shorter exam, and the likelihood of a technically successful exam with more accurate results is higher with the newer technology," Goodman said.
Moreover, the higher reimbursement means that these procedures can now pay for themselves instead of being a loss leader, he noted.
Eric Goodman, MD.
Cardiac CT branching out
Cardiac CT services can be performed in a dedicated cardiology hospital department, radiology department, interventional radiology department, hospital outpatient clinics, and multispecialty practices such as Sharp, where it is routine for radiologists to confer with cardiologists. In some areas of the U.S., mobile cardiac CT units have been deployed as part of new cardiac screening initiatives.
However, as the CMS explained in its findings, the department in which the service is performed, the type of service performed, and other factors can determine the revenue code assignment for cardiac CT services. In making its decision, the CMS weighed comments, including from those who perform CCTA in radiology departments where cardiology nursing staff prepare the patient, administer medications (such as IV beta blockers and nitroglycerin), and monitor the patient during and after the procedure.
The CCTA payment reform effort highlighted the fact that cardiac CT services are resource-intensive. Cross-department coordination between cardiology and radiology, the skill level of staff (technologists, nurses, and physicians), the expense of up-to-date CT equipment, and the amount of testing time involved are comparable to other more expensive and invasive cardiac tests.
"This is a robust test," Goodman concurred.
It is without a doubt the best test to exclude obstructive coronary artery disease and is currently used as a frontline test for people with low to intermediate risk for heart disease, with chest pain.
"It's the only noninvasive test that can diagnose coronary atherosclerosis," he continued. "We can see that, either by seeing the calcified or noncalcified plaque, even before it becomes obstructive which can dramatically change the patient outcome. This test will exponentially increase in volume because it is going to be the test to monitor people at high risk for heart disease."
For those planning to expand their cardiac CT program to include CCTA, Goodman recommended taking a dedicated course and spending time with experienced readers.
"If you know the pitfalls, you can read potentially through the motion artifacts and troubleshoot those problems," he said.
Also, Goodman said he consults with the 3D lab at nearby Sharp Memorial Hospital, rather than having in-house 3D rendering.
"Radiologists need to be familiar with the 3D radiology software to read coronary CTA," he advised. "The 3D technologist can certainly save time and provide additional information for the surgeon. It is absolutely essential to have 3D lab service moving forward."
Technologist perspectives
Kendall Youngman has been a certified CT technologist since 2008 and served as lead technologist at NEA Baptist Memorial Hospital in Jonesboro, AR, where the purchase of a new CT scanner with coronary capabilities, a close working relationship with a cardiac radiologist, and an on-staff interventional radiologist with a dedicated nursinig team led to adding CCTA.
Kendall Youngman, MSRS, RT(R)(CT)(MR).
Youngman is now an educator and director of the MRI and CT program at Arkansas State University. For AuntMinnie.com, Youngman reflected on the importance of CT technologists understanding the preferences of cardiologists and radiologists in a CCTA program.
"It really was a team approach between what a radiologist was looking for and what a cardiologist needed and how we were able to fill that gap," Youngman said. "Then we had to bring nursing in because we are not allowed to administer nitro and beta blockers to get the heart rate down and dilate the vessels."
Youngman said her team also discovered that it was better to direct reading to the radiologist (Coords recommended a cardiac-trained radiologist, SCCT level 2 or 3 certified) and make the report accessible to the cardiologist through their offsite PACS system.
With CT machines more capable and AI reconstruction coming along, it will be important for CT technologists to understand AI in postprocessing going forward, Youngman said, adding that, at her hospital, CCTA created an opportunity for CT technologists to learn about the world of CT postprocessing, software applications that reside in their own workstations, and the consistency that is required for an effective program.
"The biggest thing I champion with my students is don't be scared to talk to the radiologist," Youngman noted. "If you are going to be that liaison for the radiologist, you have to be willing to talk to them about what you can do or what you need to do so that the radiologist can make the diagnosis they need to make. It is up to you to provide a quality CT exam."
Workflow considerations
A CCTA is typically ordered electronically or by written order (then scanned into the electronic ordering system). Coords advised that groups using electronic order sets need to make sure these are updated to include CCTA, fractional flow reserve (FFR) analysis, and plaque analysis/quantification.
If those elements are only added into the notes section of an electronic order, then the chances increase of it being scheduled incorrectly or having a delayed authorization, Coords explained.
Many clinicians order with 'conditional FFR' because it will change management based on the patients' clinical history if there is 40-90% stenosis. The radiologists will then read the CCTA first and if there is 40-90% stenosis they will perform FFR analysis and then include the FFR values in the report, Coords said. This is the preferred workflow as it allows patients to get appropriate treatment more quickly, and the use of FFR helps guide patient management by preventing potentially unnecessary additional tests such as a stress test or taking patients to the cath lab when it wasn’t needed.
When a CCTA is ordered with conditional plaque, it is important that clinicians clearly document patients' history of chest pain and intermediate risk, and that cardiac evaluation is negative or inconclusive for acute coronary syndrome, Coords also said.
CCTA for screening purposes only or monitoring response to treatment is often not covered by insurance, and patients would have to pay cash.
Since the change
What's been happening since the CCTA reimbursement change? There are two components, according to Coords.
"Hospitals that are currently offering coronary CTA, they are looking at ways in which they can potentially expand because now it makes better financial sense and allows them to have the resources to appropriately expand and offer this at more centers," he said.
"I hear a lot of interested parties saying now this makes sense for them in the hospital setting," Coords said. "When it comes to the true outpatient setting, it hasn't created as much buzz because it only went up by 12%, and many smaller groups are still figuring out how to offer coronary CTA in the outpatient setting."
Coords added, "Centers that previously did not offer CCTA are looking into ways in which they can potentially purchase new scanners that can handle cardiac imaging and analysis software, as well as potentially looking at hiring cardiac-trained radiologists who can read these cases."
Editor's note: For CY 2025, the CMS used its equitable adjustment authority under section 1833(t)(2)(E) of the Social Security Act to utilize an alternative methodology to calculate the payment for the cardiac CT services in CY 2025 and subsequent years. Specifically, they finalized a temporary reassignment of the cardiac CT codes (CPT code 75572 through 75574) to APC 5572 (Level 2 imaging with contrast). As stated in the final rule, the CMS anticipated that it may take three to four years to see an impact from changes in billing practices from providers. If a significant change is not seen in the geometric mean costs after several years, the CMS will revert payment for these services to the standard OPPS payment methodology and assign the cardiac CT codes to appropriate APCs based on their geometric mean costs. See more here.
*Disclosure: IMV Medical Information Division is a sister company of AuntMinnie.com.