CPT code 75574, 75573 and 71725

CT HEART and CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY (CCTA)


General

o Certain payers consider coronary calcium scoring and/or cardiac CT and Coronary Computed Tomography Angiography (CCTA) investigational, and their coverage policies will take precedence over MedSolutions' guidelines.

o Most payers require cardiac CT studies to be performed on a 64-slice CT scanner.

o Metal artifact reduces the accuracy of CCTA. Devices that can cause this issue include, but are not limited to, surgical clips, pacemaker devices, defibrillator devices and tissue expanders.

o Cardiac testing that does not involve exposure to ionizing radiation should be strongly considered.

** Multislice CT is associated with a non-neglible risk for cancer, especially in women and younger patients.*  *JAMA 2007;298:317-323

o Contraindications to CCTA include:

** Irregular heart rhythms (e.g. atrial fibrillation/flutter, frequent irregular premature ventricular contractions or premature atrial contractions, and high grade heart block)

** Very obese patients (body mass index >40 kg/m2)

** Elevated calcium score

** CCTA should not be performed if there is extensive coronary  calcification (calcium score >1000).

** Renal insufficiency

** Inability to follow breath holding instructions

** Heart rate over 75 beats per minute

** Allergy to iodine contrast material



Anomalous Coronary Artery(ies)

o Evaluating coronary artery anomalies and other complex congenital heart disease of cardiac chambers or great vessels is an appropriate indication for CCTA.

** Report CPT®75574 for evaluating coronary artery anomalies

** Report CPT®75573 for congenital heart disease

** Can add CPT®71275 (chest CTA) to evaluate great vessels

** In cases of anomalous pulmonary venous return, can add CT abdomen and pelvis.

    The use of CCTA to rule out anomalous coronary artery(ies) should be limited to patients who need to have an anomalous coronary artery mapped prior to an invasive procedure, or who have not had a previous imaging study that clearly demonstrates an anomalous coronary artery and/or shows the anomalous artery to be patent and who are less than age 40 with a history that includes one or more of the following (aortic root echocardiography or cardiac MRI can also be considered to avoid radiation exposure):

** Persistent exertional chest pain and normal stress test

** Full sibling(s) with history of sudden death syndrome before age 30 or with documented anomalous coronary artery

** Resuscitated sudden death and contraindications for conventional coronary angiography

** Unexplained syncope (not presyncope)

** Patients should have had a thorough negative evaluation for syncope as outlined in HD-31 Syncope in the adult Head Imaging Guidelines and PACCD-5 Syncope (e.g. echocardiogram, cardiac evaluation for postural blood pressure changes, resting low blood pressure, or low heart rate, myocardial perfusion imaging study, exercise treadmill test, stress echocardiogram, or stress MRI, consideration for situational syncope) prior to considering CCTA.

** Unexplained new onset of heart failure (e.g. without atherosclerotic coronary artery disease or other known causes for cardiomyopathy) if CCTA will replace conventional invasive coronary angiography.

** Documented ventricular tachycardia (6 beat runs or greater) if CCTA will replace conventional invasive coronary angiography.

** Equivocal coronary artery anatomy on conventional cardiac catheterization

** In infants: otherwise unexplained dyspnea, tachypnea, wheezing, episodic pallor, irritability, sweating, poor feeding, and/or failure to thrive o The presence of other congenital heart disease is not a separate indication for CCTA to rule out anomalous coronary artery(ies).



 Other Indications for Cardiac CT/ CCTA:

o Congenital heart disease assessment (with procedures CPT®75573 or  CPT®71275) is indicated in both children and adults for the following:

** Determination of extra-cardiac anatomy in patients with complex congenital heart disease

** For example: great vessel relationships, bronchial collateral vessels, abdominal situs, etc.

** Pulmonary artery (PA) and Pulmonary vein assessment:

** Pulmonary artery evaluation in children who need preoperative or postoperative evaluation for PA stenosis or PA atresia

** PA caliber evaluation in children with pulmonary hypoplasia

** PA evaluation to look for another anatomic structure impinging on the  PA, or to look for airway/bronchial compromise by an enlarged PA or     other mediastinal vessel.

** Assessment of the course of drainage of pulmonary veins when chest x-ray suggests anomalous pulmonary venous drainage.

** Coarctation of the aorta or interruption of the aortic arch suspected on echocardiography.

** Evaluation of the arterial supply and venous drainage in children with bronchopulmonary sequestration.

o Vasculitis/Takayasu's/Kawasaki's disease can be imaged with CCTA (CPT®75574).

o Cardiac CT (CPT®75572) can be used to assess cardiac tumor or mass, pericardial mass, pericarditis/ constrictive pericarditis, complications of cardiac surgery, evaluation of post-operative anatomy and surgically corrected systemic-to-pulmonary artery shunts and intra-cardiac baffles, etc.

o Cardiac CT (CPT®75572) can be used to evaluate cardiac thrombus in patients with technically limited echocardiogram, MRI, or transesophageal echocardiogram.

o Cardiac CT (CPT®75572) can be used to evaluate clinical suspicion of arrhythmogenic right ventricular dysplasia or arrhythmogenic cardiomyopathy (ARVD/ARVC), especially if patient has presyncope or syncope if the clinical suspicion is supported by established criteria for ARVD (see PACCD-3 Evidence Based Clinical Support) or if the patient has documented Brugada’s syndrome.

** If right ventricular abnormalities are already identified by echo or other techniques, cardiac CT may not be necessary.

** Young patients with right bundle branch block, unexplained syncope, and “normal” echo can undergo cardiac MRI (CPT®75557 or CPT®75561) or cardiac CT (CPT®75572) to rule out ARVD/ARVC.

o Native aortic abnormalities can be investigated with cardiac CT (CPT®75572)if echocardiogram is indeterminate.



 Radiation Dose

o Radiation dosage for CCTA varies by facility and the particular protocol used. The American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging states that “as a general rule a multi-detector CT scan   encompassing the heart should not result in an effective dose of greater than 12 mSv.”*

o 64-slice CT scanners can deliver a radiation does from 15-25 mSv (especially in women due to breast tissue density).

o Multislice CT is associated with a non-neglible risk for cancer, especially in women and younger patients.* *JAMA 2007; 298:317-323

o Sophisticated gating and other techniques can reduce the radiation dose of cardiac CT studies to less than 5 mSv. Application of these techniques is increasing nationwide.*  *J Am Coll Radiol 2005;2:471-477

o Dual source scanners decrease radiation exposure by approximately one third.

o Conventional coronary angiography typically delivers a radiation dose of 3 to 6 mSv.*

*J Am Coll Cardiol 2007;50(15):1469-1475

o Newer imaging technologies will allow for reduced radiation exposure