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How to Report a Coronary CT Angiography
Michael Poon, MD, FACC
Director of Cardiac MR/CT Program
Cabrini Medical Center
Associate Professor of Medicine
Mount Sinai School of Medicine
DISCLOSURE STATEMENT
Michael Poon, MD has disclosed the information listed below. Any
real or apparent conflict of interest related to the content of the
presentation has been resolved.
Affiliation/Financial Interest
Grant Support & Consultant
Consultant
Consultant
Consultant
Consultant
Organization
Siemens Medical Solutions
TeraRecon Inc.
Bracco Diagnostic Inc.
Vital Images
Chase Medical Inc.
Duke-ACC Think Tank Meeting (2006)
on
“Dimensions of Cardiovacular Imaging Quality”
“Better reporting translates into better
overall quality of care”
Dr. Ray Gibbons, President of the AHA (2006-7)
Documentation Requirements
(CMS)
•
•
•
Each claim must be submitted with ICD-9-CM codes
that reflect the condition of the patient, and indicate the
reason(s) for which the service was performed. Claims
submitted without ICD-9-CM codes will be returned.
The documentation of the study requires a formal
written report, with clear identifying demographics, the
name of the interpreting provider, the reason for the
tests, an interpretive report and copies of images. The
computerized data with image reconstruction should
also be maintained.
Documentation must be available to Medicare upon
request
Optimal Report Generation
•Indication
•Clinical History
•Procedure
•Findings
•Impression
Optimal Report Generation
•Indication
•Clinical History
•Procedure
•Findings
•Impression
New Category III CPT Codes for Coronary
CTA
•
0144T CT, heart, without contrast material, including image postprocessing & quantitative
evaluation of coronary calcium
•
0145T CT heart, without contrast material followed by contrast material(s) & further sections,
including cardiac gating and 3D image post-processing; cardiac structure & morphology
•
0146T CT angiography of coronary arteries (CCTA) (including native & anomalous coronary
arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
•
0147T CCTA with quantitative evaluation of coronary calcium
•
0148T Cardiac structure & morphology and CCTA, without quantitative evaluation of coronary
calcium
•
0149T Cardiac structure & morphology and CCTA, with quantitative evaluation of coronary calcium
•
0150T Cardiac structure and morphology in congenital heart disease
•
0151T CT, heart, without contrast material followed by contrast material(s) & further sections,
including cardiac gating and 3D image post-processing; function evaluation (L & R ventricular
function, ejection fraction, & segmental wall motion)
(effective Jan 1, 2006)
New Category III CPT Codes for Coronary
CTA
•
0145T CT heart, without contrast material followed by contrast material(s) & further sections,
including cardiac gating and 3D image post-processing; cardiac structure & morphology
•
0146T CT angiography of coronary arteries (CCTA) (including native & anomalous coronary
arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
•
0148T Cardiac structure & morphology and CCTA, without quantitative evaluation of coronary
calcium
•
0150T Cardiac structure and morphology in congenital heart disease
•
+0151T CT, heart, without contrast material followed by contrast material(s) & further sections,
including cardiac gating and 3D image post-processing; function evaluation (L & R ventricular
function, ejection fraction, & segmental wall motion)
(effective Jan 1, 2006)
Indications
•Model LCD
(WWW.SCCT.ORG/ADVOCACY/INDEX.CFM
•Appropriateness Criteria
(www.acc.org/qualityandscience/clinical/to
pic/topic.htm)
Indications
•Model LCD
(WWW.SCCT.ORG/ADVOCACY/INDEX.CFM
•Appropriateness Criteria
(www.acc.org/qualityandscience/clinical/to
pic/topic.htm)
Report generation
•1. Indication = ICD-9 code(s)
Model LCD
ICD-9-CM
Optimal Report Generation
•Indication
•Clinical History
•Procedure
•Findings
•Impression
Model Local Coverage Determination (LCD)
Indications 1 - 10
• 1. Coronary CTA used as a first test to assess
the cause of chest pain.
• 2. Coronary CTA used as a triage tool to
invasive coronary angiography following a stress
test that is equivocal or suspected to be
inaccurate.
• 3 Coronary CTA to evaluate the cause of
symptoms in patients with known coronary artery
disease.
Model LCD
• 4. Coronary CTA to evaluate the cause of chest
pain or dyspnea in patients with prior bypass
surgery or intracoronary artery stent placement*.
• 5. Coronary CTA for suspected congenital
anomalies of the coronary circulation.
• 6. Coronary CTA for evaluation of acute chest
pain in the emergency room*.
* New indications since LCD on 71275
Model LCD
•7. CTA for the assessment of coronary or
pulmonary venous anatomy
• 8. Use of coronary CTA prior to non-coronary
artery cardiac surgery.
* New indications since LCD on 71275
Model LCD
9. Quantitative evaluation of coronary calcium to be
used as a triage tool in patients with typical chest
pain and unknown Agatston score to determine
appropriateness of coronary CTA vs. catheter
coronary angiography*.
10. Quantitative evaluation of coronary calcium to be
used as a triage tool for lipid-lowering therapy in
patients with moderate to high Framingham Risk
score*.
* New indications since LCD on 71275
Appropriateness Indications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Evaluation of chest pain syndrome in patients with intermediate pre-test
probability of CAD.
Evaluation of acute chest pain in patients with intermediate pre-test
probability of CAD.
Evaluation of suspected coronary anomalies
Evaluation of chest pain syndrome in patients with uninterpretable or
equivocal stress test.
Assessment of complex congenital heart disease including anomalies of
coronaries, great vessels, and cardiac chambers and valves.
Evaluation of coronary arteries in patients with new onset heart failure to
assess etiology.
Evaluation of cardiac mass
Evaluation of pericardial conditions
Evaluation of pulmonary vein anatomy prior to invasive radio frequency
ablation for atrial fibrillation.
Non-invasive coronary vein mapping prior to placement of biventricular
pacemaker
Noninvasive coronary arterial mapping, including internal mammary artery,
prior to repeat cardiac surgical revascularization.
Evaluation of suspected aortic dissection or thoracic aortic aneurysm.
Evaluation of suspected pulmonary embolism.
CCT Coverage
§ As of December 1, 2006 all Medicare Carriers
had coverage policies/articles in place for
CCTA
§ Major health plans are following the trend
§
§
§
§
CIGNA
Aetna, effective July 1, 2007
UHC/Oxford
More than 8 BCBS Plans with coverage
§ WellPoint and BCBS-FL with limited coverage-1
Indication (i.e. evaluation of congenital coronary
anomalies following unsuccessful invasive angiography)
Optimal Report Generation
•Indication
•Clinical History
•Procedure
•Findings
•Impression
Procedure
CT Angiography of the coronaries with and without contrast was performed
using a 16/32/40/64/128/256-detector CT scanner. Axial images were obtained
from the level of the subclavian artery/aortic arch/ascending aorta through to
the diaphragm at 0.6 collimation mm section thickness during breath hold with
or without ECG-gated current modulation. 65 -110 ml of intravenous contrast
was injected via a right/left antecubital intravenous catheter at 4-7 ml/sec with
50 ml of (dual flow (30C/70S) or 50 ml of saline saline) infused immediately
afterward. Image reconstructions were performed at 0.6 mm thickness/0.4
interval mm using retrospective cardiac gating. 3D and multiplanar
reconstructions were performed. 0-40 mg of Lopressor (+/- additional calcium
channel blocker) was given intravenously and the heart rate at the time of
image acquisition was approximately 65 bpm. One dose of 0.4 mg
sublingual/sublingual nitroglycerin was given ~5 min prior to the CTA. The
heart rhythm was regular/irregular with/without frequent atrial or
ventricular premature beats.
Procedure
Overall Quality of the study:
Excellent: no artifacts
Good: minor artifact but good diagnostic quality
Acceptable: Moderate artifacts but adequate diagnostic quality
Poor/Suboptimal: Severe artifacts and not readable
Suboptimal due to:
a. Motion: cardiac (tachycardial or bradycardia), irregular heart rhythm,
respiratory, voluntary or involuntary body motion.
b. Poor overall contrast enhancement: poor timing of the contrast
arrival, large body habitus.
c. Metallic implants (sternal wires, pacemaker or defribrillator wires,
surgical clips, or tissue expander)
d. Calcium
Respiratory Artifacts
High Heart Rate: Double Images Artifacts
Metal Artifacts
Category III CPT Codes for Coronary CTA
• 0146T Computed Tomography angiography of
coronary arteries (including native and
anomalous coronary arteries, coronary bypass
grafts), without quantitative evaluation of
coronary calcium
• 0147T Computed Tomography angiography of
coronary arteries (including native and
anomalous coronary arteries, coronary bypass
grafts), with quantitative evaluation of coronary
calcium
(effective Jan 1, 2006)
Optimal Report Generation
•Indication
•Clinical History
•Procedure
•Findings
•Impression
Calcium Score
Interpretation
0
No identifiable atherosclerotic plaque.
Very low cardiovascular disease risk.
Less than 5% chance of presence of
coronary artery disease.
A Negative Examination.
1-10
Minimal plaque burden.
Significant coronary artery disease very
unlikely.
11-100
Mild plaque burden.
Likely mild or minimal coronary
stenosis.
101-400
Moderate plaque burden.
Moderate non-obstructive coronary
artery disease highly likely.
Over 400
Extensive plaque burden.
High likelihood of at least one
significant coronary stenosis (>50%
diameter).
New Category III CPT Codes for Coronary
CTA
• 0146T Computed Tomography angiography of
coronary arteries (including native and
anomalous coronary arteries, coronary bypass
grafts), without quantitative evaluation of
coronary calcium
• 0147T Computed Tomography angiography of
coronary arteries (including native and
anomalous coronary arteries, coronary bypass
grafts), with quantitative evaluation of coronary
calcium
(effective Jan 1, 2006)
Subjective Evaluation using MPR
There is a mixed nonobstructive
(<50% diameter stenosis) plaque
seen in the mid LAD. The LAD
wraps around the apex. The
proximal first diagonal branch
has a obstructive noncalcified
(>50%) non-calcified plaque and
is a bifurcating vessel. Mid LAD
has small nonobstructive mixed
plaques. Distal LAD is normal.
Quantitative Analysis Using CMPR
Sample Report for 0146T
Final Impression:
1. Normal Study
2. Mild Disease (<25%)
3. Moderate Disease (26 - 50%)
4. Moderate severe Disease (51 - 75%)
5. Severe Disease (76 –99%)
6. Totally occluded vessel
7. Uninterpretable Study
8. Other findings:
A. Coronary Anomaly:
B. Atrial Appendage Thrombus
C. Bicuspid Aortic Valve
D. Extensive Aortic Valve Calcification
E. Other___________________
Cardiac Incidental Findings
Controversial Topic: Many Radiologists prefer Cardiology
input.
Anomalous Coronary Artery
Curved MPR View of the Left Main from RCA
3DVRT View of the RCA from the Left Main
Poon M, Nat Clin Pract Cardiovasc Med. 2006 May;3(5):265-75. Review
DOT Sign
The Prevalence of Anomalous Origin of Coronary Artery: A Multi-Center Study
†Zeng Y, ‡Mendelsohn SL, Karimjee N, ‡Day R, †Poon M
†Cabrini Medical Center, New York, NY, ‡Zwanger-Pesiri Radiology, E. Setauket, NY, Life Imaging, Huntsville, TX
BACKGROUND
Reported
incidence of coronary artery anomalies vary
between 0.4% and 0.8% in angiographic studies and 0.3% in
an autopsy series. MDCT is evolving rapidly as a noninvasive
imaging method of choice for the evaluation of coronary
anomaly; however the frequency of such finding has not been
reported in MDCT studies. We aimed to investigate the
prevalence of anomalous origin of coronary artery in three
diagnostic imaging centers.
RESULTS
RESULTS
LM from right sinus between AO
0.06%
and LA
LM from right sinus between AO
0.03%
and PA
LCX from right sinus
0.32%
RCA from left sinus
0.23%
Total
0.64%
Left circumflex (LCX) coronary artery from right coronary sinus
LM-II
LM-I 1
2 5%
9%
RCA
11
50%
LCX
8
36%
METHODS
Left main (LM) coronary artery from right coronary sinus
A
- Anomalous LM courses between ascending aorta and pulmonary artery
artery
retrospective chart review of a 3356 patient registry from
three diagnostic imaging centers in the United States (2 from
New York and one from Texas). 2007 patients from Cabrini
Medical Center, NY; 584 from Life Imagine, Texas; and 765
patients from Zwanger-Pesiri Radiology groups, New York.
All patients were referred for the evaluation of suspected or
known coronary artery disease on a 16-, 64-, or 128-slice
MDCT scanner.
Right coronary (RCA) artery from right coronary sinus
RESULTS
22 patients (0.66%) with anomalous origin of coronary artery
including: anomalous origin of the left circumflex coronary
artery from right coronary sinus which courses anteriorly
between ascending aorta and left atrium (n=11, 0.32%);
anomalous origin of right coronary artery from left coronary
sinus which travels posteriorly between the ascending aorta
and right ventricular outflow tract (n=8, 0.23%); anomalous
origin of left main coronary artery from right coronary sinus
which courses anteriorly between ascending aorta and left
atrium (n=2, 0.06%) or courses between ascending aorta and
pulmonary artery (n=1, 0.03%).
- Anomalous LM courses between ascending aorta and left atrium
CONCLUSIONS
Adult
anomalous origins of coronary artery are not very
common and are usually incidental findings of diagnostic
catheterization or MDCT studies. Among the various anomalies
of the origin, left circumflex coronary artery anomalies are the
most frequent (50 %), followed by the right coronary artery (36
%) and the left main coronary artery (14%). Anomalous origin
of coronary artery that courses between the great vessels is
associated with the risks of syncope, myocardial ischemia and
sudden death. MDCT may emerge as the imaging modality of
choice for the evaluation of such coronary anomaly.
Kawasaki’
s Disease
AV Fistula
Conus br to Anterior Cardiac Vein
LM to PA
Giant Coronary Aneurysm
ASD
Double Chambered LV
Sanz J, Rius T, Kuschnir P, Macalusa F, Fuster V, Poon M. Circulation 2004
Non-Cardiac Incidental Findings
Controversial Topic: Majority of Cardiologists prefer Radiology Over-read.
The Prevalence and Significance of Incidental Findings
During Cardiac 64- or 128- Slice Computed Tomography
Dinh H*, Stecko J†, Mendelsohn S‡, Day B‡, Poon M†.
*David Geffen School of Medicine at UCLA, Los Angeles CA, USA. †Cabrini Medical Center, New York, NY, USA. ‡Zwanger-Pesiri Radiology,
E. Setauket, NY, USA.
BACKGROUND
•The number of outpatient private practice
facilities offering multi-row detector computed
tomography (MDCT) is on the rise.
•Non-cardiac pathology may be imaged and
missed if not routinely assessed by the
interpreting physician.
•Few studies have looked at the prevalence of
extracardiac incidental findings at outpatient
facilities.
N = 511
Incidental
Findings
(No.
Patients,
%)
Pulmonar
y
189 (37%)
Vascular
105 (21%)
Hepatic
61 (12%)
PURPOSE AND HYPOTHESIS
We investigated the frequency and significance of
incidental findings during cardiac MDCT.
MATERIALS AND METHODS
A total of 512 consecutive patients underwent 64or 128-slice MDCT (440 and 72, respectively)
between the period of September 2005 to March
2007 at two out-patient private practices.
Radiology and cardiology final reports were
reviewed for incidental findings, which were
defined as non-cardiac diagnoses not previously
known. Findings of clinical significance were
defined as those requiring follow up diagnostic
imaging or intervention.
RESULTS
A total of 575 new, extra-cardiac findings were
identified. Of this, 187 (33%) were clinically
significant. Per patient analysis showed that 117
(23%) of patients had at least one new clinically
significant finding. The prevalence of all
incidental findings, significant clinical findings,
and specific significant incidental findings are
summarized in the table below.
Gastrointestinal
41 (8%)
Clinically
Significa
nt
Incidenta
Clinically Significant Diagnoses
l
(No. lesions)
Findings
(No.
Patients,
•Nodule/granuloma (>1cm) -83
%)
•Cavitated granuloma -1
•Mass (<1cm) -1
•Pleural thickening/plaques -10
48 (9%)
•Chest/mediastinal lymph nodes
(>1cm) -14
•Metastatic cancer -1
•Pulmonary embolus -1
•Ascending aorta aneurysm -8
•Descending aorta aneurysm -3
•Aortic arch aneurysm -1
15 (3%) •Type B dissection -1
•Splenic artery aneurysm (>1.5 cm) 3
•Celiac artery aneurysm (>1.5 cm) -3
3 (0.6%)
•Mass 3.5 cm -1
•Lesions (not cysts) -2
3 (0.4%)
•Hiatal hernia (entire stomach in
thorax) -1
•Mesenteric lymph node >1.5 cm -1
•Pancreatic necrosis/fat/atrophy -2
Thyroid
25 (5%)
25 (5%)
•Thyromegaly -3
•Lesion/mass/nodule -22
Adrenal
22 (4%)
21 (4%)
•Adenoma (>1cm) -19
•Nodule (>1cm) -1
•Myelolipoma -1
Orthopedi
c
9 (2%)
1 (0.2%)
•Sclerosis vertebral body/mets -1
4 (0.8%)
•Angiomyolipoma -1
•Breast calcification -1
•Breast soft density -1
•Axillary lymph node -1
Other
47 (9%)
EXAMPLES OF INCIDENTAL FINDINGS
CONCLUSIONS
Outpatient private practice per patient prevalence of
clinically significant non-cardiac incidental findings is
about 23% during coronary MDCT examinations which is
similar to published data at academic centers and inpatient
settings. Review of all imaging data is important to avoid
missing potentially treatable disease.
SCCT Action Item
Quality Task Force: Dr. W. Guy Weigold
Cardiac CT Data Elements and Standardized
Reporting: Dr. Gil Raff
WWW.SCCT.ORG
New Category III CPT Codes for Coronary
CTA
•+0151T Computed tomography, heart,
without contrast material followed by
contrast material(s) and further
sections, including cardiac gating and
3D image post processing; function
evaluation (left and right ventricular
function, ejection fraction and
segmental wall motion)
(effective Jan 1, 2006)
CT Evaluation of Cardiac Function
ASSESSMENT OF LEFT AND RIGHT VENTRICULAR FUNCTION WITH MULTI -DETECTOR ROW COMPUTED TOMOGRAPHY
(MDCT): COMPARISON WITH CARDIAC MAGNETIC RESONANCE (CMR)
Teresa Rius, M.D., Javier Sanz, M.D., Paola Kuschnir, M.D. , Rafael Salguero, M.D. , Roman Fiscbach, M.D. , Bernd Ohnesorge,
2006
Ph.D., Valentin Fuster, M.D., Ph.D. , Michael Poon, M.D.
CT function: Left Ventricle
A
B
C
Simultaneous and automatic displays of 3 multiplanar
reconstructions of the left ventricle in end-systole generated by the
cardiac volume analysis software
Figure A: Long-axis four chamber view of LVESV.
Figure B: Long-axis two chamber view of LVESV
Figure C: Short axis view of LVESV
CT function: Right Ventricle
A
B
C
Simultaneous and automatic displays of 3 multiplanar reconstructions of the right
ventricle in end-systole generated by the cardiac volume analysis software
Figure A: Long-axis four chamber view of RVESV.
Figure B: Long-axis two chamber view of RVESV
Figure C: Short axis view of RVESV
0151T: Normal Values (CMR)
Eike Nagel, Myocardial Function and Stress Imaging in Cardiovascular Magnetic Resonance, Martin Dunitz 2003
0151T: Normal Values (CMR)
Eike Nagel, Myocardial Function and Stress Imaging in Cardiovascular Magnetic Resonance, Martin Dunitz 2003