Welcome, everyone, to this session, which is titled Workflow and Billing Considerations. My name is Tim Bateman. I'm co-director of cardiovascular radiologic imaging at MidAmerica Heart Institute in Kansas City, Missouri. These are my disclosures. What we are going to discuss is shown on this slide, and we are going to start with preauthorization issues for hybrid SPECT and for hybrid PET myocardial perfusion imaging. So let's start with SPECT. So first off, there is no preauthorization issue under either the physician fee schedule or under the hospital payment schedules for SPECT or for hybrid SPECT, because both pay exactly the same. So regardless of how one does attenuation correction with SPECT, whether you do it or whether you don't do it, you get paid the same. And if you do do attenuation correction with SPECT, it doesn't matter whether you do it with line sources or whether you do it with CT or whether you do it with machine learning, artificial intelligence, you get paid exactly the same. So there is no preauthorization issue, therefore. The payers don't care whether you do or whether you don't do SPECT with or without attenuation correction or with or without CT. There is, of course, a major provider issue because hybrid SPECT incurs hard costs because the CT scanner obviously adds a major additional cost to the technical side of things. The labor costs go up because you have to have in your employee either a certified CT tech or a nuclear tech who has additional training to run a CT scanner. And there's additional MD work because the MD has to look at the CT images and incorporate those findings into the report. So all of these things deserve recognition on both the technical and the professional side. So the professional societies are working on this matter. It's important in the meantime to provide best practice medicine, and you've heard about that throughout this course. Now there is an additional quality of care issue that hybrid SPECT confers over and above dedicated SPECT, and that is the detection of subclinical coronary disease. So if a patient has no known coronary disease, it's important to get that CT scan one way or the other. It's best if you can get it with a hybrid device or get it on the same day as part of the myocardial perfusion study on a remote CT scanner. But if your plan is to assess coronary calcium, it's important that you do not request that coronary calcium score along with the authorization to do the myocardial perfusion SPECT. Because if you do, many of the payers are probably going to deny the MPI right off the bat. So what are your options therefore? Well your options are to, you've really got just four options. One is to submit the bill, and if the payer refuses to pay, just forgive it. That's what we do in our hospital network. That's something you have to work out with your hospital, or if you're in a practice, you have to just work that out with your partners. You cannot submit the bill at all. That of course is simpler from the patient standpoint. You can charge the patient up front, but need to keep that at a very token amount, and the patient needs to be aware that there is going to be a token charge. Usually the Medicare rate for that would be about $68. So somewhere in that $50 to $70 range would be reasonable. Or you can just estimate the coronary calcium from the non-gated scan, either visually or with AI software, and not actually quantify the calcium at all. But the most important thing here is don't request the MPI at the time of ordering, don't request the calcium score at the time of ordering the MPI, or most likely you're going to have a denial. So in summary, with respect to SPECT, there are no problems with pre-authorization, providing you're not trying to get approval for coronary artery calcium. It's unfair to providers. It's best practices for patients. The professional medical societies are working on this. Think ahead to the future. With respect to PET, there is a potential issue, because under both the physician fee schedule and the hospital payment schedules, a PET CT does pay a higher technical and a professional fee than a dedicated PET myocardial perfusion study does. So we'll come back to that in just a second. However, the same issue pertains with respect to coronary artery calcium scoring. We do think it's important to assess coronary calcium with PET, just as with SPECT. And so you've got the same four options. Do not request a PET MPI with coronary calcium, or you probably will get a rejection, a denial. So you've got these same four options that we just talked about. Now, because you get a higher payment with PET CT, both technical and professional, than with a dedicated PET, you may find that if there is a provider in your area, a competitive provider with a dedicated PET scanner, in theory, a payer could attempt to channel a referral to the less expensive alternative. We have seen this. We haven't seen this for a couple of years now, and we were able to get that pattern reversed. However, please let ASNIC know if you become aware of any instance of this inappropriate redirection of patient referrals, and ASNIC will be of assistance to you. What about hybrid study interpretation? This has probably been discussed in an earlier session. I'm going to go over it briefly, however. Hybrid study interpretation introduces an anatomic interpretation in addition to the typical physiologic interpretation of a typical MPI study. So we have not just nuclear data, but now CT data to consider as well. Furthermore, depending upon the number of CT detectors loaded onto the hybrid device, the field of view can cover multiple organ systems. Sometimes several bed positions are required, as in sarcoid imaging, for example, or infection imaging. Some common indications require, in fact, whole body imaging. So the field has suddenly become a little bit more complicated than it used to be when the field of view was narrowed right down just to the heart. So different specialists historically have had expertise when we start talking about hybrid imaging. So obviously, cardiologists have had extensive training and experience in nuclear cardiology. Nuclear medicine specialists, likewise, have had experience in that field. Radiologists have had extensive experience in CT and perhaps not as much in myocardial perfusion imaging. FDG, hotspot images, nuclear medicine has been primarily exposed and trained in that arena, less so cardiologists and radiologists. But in hybrid imaging, we have this kind of blend of necessity for understanding of all three of these in order to do expert interpretations. So different patterns have emerged as people have recognized that they either needed to share interpretations or they had to get trained extensively to be able to read these studies independently. So dependent upon the amount of training, a cardiologist might read these alone and seek overreads as needed, or a nuclear medicine specialist might do this and seek overreads as needed, or a radiologist might do it. In some major centers, usually academic or university centers, there may be reads done by cardiologists and or nuclear medicine specialists and or radiologists reading together whatever is essential to be in compliance with your hospital or your practice credentialing criteria. Now, a few fundamentals. Once you introduce CT, at least the lab director has to be level three trained in cardiac CT and cardiotechnologists need to be certified as well in cardiac CT. Ideally, all independent interpreters should have some type of statement of proficiency as well and should keep up on required amount of CME, an example for a cactal lab accreditation. When it comes to report generation, there are a few things that I wanted to point out that I think are especially important and may not be thought about until you actually get into the practice of this. So first of all, these are non-standard scans, okay? Even in the most typical scenario where one is just imaging around the heart as in a typical myocardial perfusion study, we're only imaging a part of the chest. So only a part of the lungs are showing up in the field of view. So obviously, this is a non-standard view of the chest. The slice thickness is not standard. The images are often fairly low resolution. The MA settings and the voltage settings are different from a standard chest CT and dependent upon how much control you may even have over the MA and KV settings on the CT that accompanies your hybrid device, the images may be quite noisy. So given that these are non-standard scans, there are no current rules or case law about the interpretation. The prevailing practice is to inspect and report pertinent abnormal findings and to retain the CT images in the standard practice storage. You could consider a disclaimer statement. We have done this for more than 20 years. This is a low resolution, non-diagnostic CT scan of the chest for attenuation correction and is not intended for any other purpose would be one consideration. You should not fool yourself that you can make high quality diagnoses based on these non-standard scans. You can certainly recognize abnormalities. Sometimes you can zero in on a likelihood, but in most cases, you're going to have to acquire a standard acquisition in order to be certain about the diagnosis. It is important when you see something that is potentially critical to get on the phone and call the referring physician. You obviously need to put it into the report, but that by itself is not sufficient. So if you start seeing things like masses in the breasts, masses in the lungs, it's important to call the referring physician to be sure that that sort of critical finding is not somehow missed in a report. Often when a physician refers a patient for a particular reason, dependent upon the extraction process and the practice, what comes back as a focus is the reason for the report and other things can be missed. So malignancies, infections, for cardiology referrals, ground glass opacities can be particularly important because they can be early signs of amiodarone toxicity. As you know, many of our patients are on amiodarone and you don't want to miss the opportunity to tip off a cardiologist that a patient is potentially developing this type of toxicity. A second very important point is if sending out images for overread, be sure to indicate that you have done so in your report, so that the referring physician is aware to be looking for that second report. We have also learned that it's important to have in place a foolproof mechanism to ensure that the overread report actually gets to the referring physician. Now this is a very important point because if you're not careful, the overread report will not go to the referring physician, but will come back to the reading physician. And the reading physician may not even be back reading scans for the next two to three weeks and may not even get that report. So think about your process if you are sending out images for an overread. We rarely send out images for an overread to avoid those types of problems. I mean, basically, if we see an abnormality, given that these images are not standard, we just request in our report to the referring physician that they acquire a standard acquisition CT or whatever imaging procedure would be appropriate. So for example, if we saw something in the breast, we would say, you know, recommend mammography, or if we saw something in the lungs, we would recommend a standard acquisition full lung CT. Okay, so most abnormalities require a standard acquisition, full organ CT for a full anatomic assessment of an abnormal finding. And finally, hybrid billing challenges. The charge should be the same, regardless of whether there is a single physician that's interpreting the study, whether there are two physicians interpreting the study together, or whether there is an overread that's taking place. Remember that the patient is not a party to any of these subcontracts that are going on. Okay, the patient in no circumstances should be direct billed by an overreader. Okay, and finally, as I've already emphasized, remember, the primary reader carries the full liability for the first and second read getting to the referring MD. So think your way carefully through this whole process of the second read, if there is a second read, how that actually gets to the referring MD and doesn't somehow invisibly end up in Epic or Cerner or something like that, but doesn't actually directly get to the referring MD as a part of the report. Thank you for your attention to this section on pre-authorization and billing.

Workflow and Billing Considerations

preauthorization issues

hybrid SPECT

hybrid PET

myocardial perfusion imaging