How to Report a Coronary CT Angiography Michael Poon, MD, FACC

How to Report a Coronary CT AngiographyMichael Poon, MD, FACCDirector of Cardiac MR/CT ProgramCabrini Medical CenterAssociate Professor of MedicineMount Sinai School of Medicine

DISCLOSURE STATEMENTMichael Poon, MD has disclosed the information listed below. Anyreal or apparent conflict of interest related to the content of thepresentation has been resolved.Affiliation/Financial InterestGrant Support & ConsultantConsultantConsultantConsultantConsultantOrganizationSiemens Medical SolutionsTeraRecon Inc.Bracco Diagnostic Inc.Vital ImagesChase Medical Inc.

Duke­ACC Think Tank Meeting (2006)on“Dimensions of Cardiovacular Imaging Quality”“Better reporting translates into betteroverall quality of care”Dr. Ray Gibbons, President of the AHA (2006­7)

Documentation Requirements(CMS)• Each claim must be submitted with ICD­9­CM codesthat reflect the condition of the patient, and indicate thereason(s) for which the service was performed. Claimssubmitted without ICD­9­CM codes will be returned.• The documentation of the study requires a formalwritten report, with clear identifying demographics, thename of the interpreting provider, the reason for thetests, an interpretive report and copies of images. Thecomputerized data with image reconstruction shouldalso be maintained.• Documentation must be available to Medicare uponrequest

Optimal Report Generation•Indication•Clinical History•Procedure•Findings•Impression

Optimal Report Generation•Indication•Clinical History•Procedure•Findings•Impression

New Category III CPT Codes for CoronaryCTA• 0144T CT, heart, without contrast material, including image postprocessing & quantitativeevaluation of coronary calcium• 0145T CT heart, without contrast material followed by contrast material(s) & further sections,including cardiac gating and 3D image post­processing; cardiac structure & morphology• 0146T CT angiography of coronary arteries (CCTA) (including native & anomalous coronaryarteries, 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 coronarycalcium• 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 post­processing; function evaluation (L & R ventricularfunction, ejection fraction, & segmental wall motion)(effective Jan 1, 2006)

New Category III CPT Codes for CoronaryCTA• 0145T CT heart, without contrast material followed by contrast material(s) & further sections,including cardiac gating and 3D image post­processing; cardiac structure & morphology• 0146T CT angiography of coronary arteries (CCTA) (including native & anomalous coronaryarteries, coronary bypass grafts), without quantitative evaluation of coronary calcium• 0148T Cardiac structure & morphology and CCTA, without quantitative evaluation of coronarycalcium• 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 post­processing; function evaluation (L & R ventricularfunction, 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/topic/topic.htm)

Indications•Model LCD(WWW.SCCT.ORG/ADVOCACY/INDEX.CFM•Appropriateness Criteria(www.acc.org/qualityandscience/clinical/topic/topic.htm)

Report generation•1. Indication = ICD­9 code(s)Model LCD

ICD­9­CM

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 assessthe cause of chest pain.• 2. Coronary CTA used as a triage tool toinvasive coronary angiography following a stresstest that is equivocal or suspected to beinaccurate.• 3 Coronary CTA to evaluate the cause ofsymptoms in patients with known coronary arterydisease.

Model LCD• 4. Coronary CTA to evaluate the cause of chestpain or dyspnea in patients with prior bypasssurgery or intracoronary artery stent placement*.• 5. Coronary CTA for suspected congenitalanomalies of the coronary circulation.• 6. Coronary CTA for evaluation of acute chestpain in the emergency room*.* New indications since LCD on 71275

Model LCD•7. CTA for the assessment of coronary orpulmonary venous anatomy• 8. Use of coronary CTA prior to non­coronaryartery cardiac surgery.* New indications since LCD on 71275

Model LCD9. Quantitative evaluation of coronary calcium to beused as a triage tool in patients with typical chestpain and unknown Agatston score to determineappropriateness of coronary CTA vs. cathetercoronary angiography*.10. Quantitative evaluation of coronary calcium to beused as a triage tool for lipid­lowering therapy inpatients with moderate to high Framingham Riskscore*.* New indications since LCD on 71275

Appropriateness Indications1. Evaluation of chest pain syndrome in patients with intermediate pre­testprobability of CAD.2. Evaluation of acute chest pain in patients with intermediate pre­testprobability of CAD.3. Evaluation of suspected coronary anomalies4. Evaluation of chest pain syndrome in patients with uninterpretable orequivocal stress test.5. Assessment of complex congenital heart disease including anomalies ofcoronaries, great vessels, and cardiac chambers and valves.6. Evaluation of coronary arteries in patients with new onset heart failure toassess etiology.7. Evaluation of cardiac mass8. Evaluation of pericardial conditions9. Evaluation of pulmonary vein anatomy prior to invasive radio frequencyablation for atrial fibrillation.10. Non­invasive coronary vein mapping prior to placement of biventricularpacemaker11. Noninvasive coronary arterial mapping, including internal mammary artery,prior to repeat cardiac surgical revascularization.12. Evaluation of suspected aortic dissection or thoracic aortic aneurysm.13. Evaluation of suspected pulmonary embolism.

CCT Coverage• As of December 1, 2006 all Medicare Carriershad coverage policies/articles in place forCCTA• Major health plans are following the trend• CIGNA• Aetna, effective July 1, 2007• UHC/Oxford• More than 8 BCBS Plans with coverage• WellPoint and BCBS­FL with limited coverage­1Indication (i.e. evaluation of congenital coronaryanomalies following unsuccessful invasive angiography)

Optimal Report Generation•Indication•Clinical History•Procedure•Findings•Impression

ProcedureCT Angiography of the coronaries with and without contrast was performedusing a 16/32/40/64/128/256­detector CT scanner. Axial images were obtainedfrom the level of the subclavian artery/aortic arch/ascending aorta through tothe diaphragm at 0.6 collimation mm section thickness during breath hold withor without ECG­gated current modulation. 65 ­110 ml of intravenous contrastwas injected via a right/left antecubital intravenous catheter at 4­7 ml/sec with50 ml of (dual flow (30C/70S) or 50 ml of saline saline) infused immediatelyafterward. Image reconstructions were performed at 0.6 mm thickness/0.4interval mm using retrospective cardiac gating. 3D and multiplanarreconstructions were performed. 0­40 mg of Lopressor (+/­ additional calciumchannel blocker) was given intravenously and the heart rate at the time ofimage acquisition was approximately 65 bpm. One dose of 0.4 mgsublingual/sublingual nitroglycerin was given ~5 min prior to the CTA. Theheart rhythm was regular/irregular with/without frequent atrial orventricular premature beats.

ProcedureOverall Quality of the study:Excellent: no artifactsGood: minor artifact but good diagnostic qualityAcceptable: Moderate artifacts but adequate diagnostic qualityPoor/Suboptimal: Severe artifacts and not readableSuboptimal 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 contrastarrival, 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 ofcoronary arteries (including native andanomalous coronary arteries, coronary bypassgrafts), without quantitative evaluation ofcoronary calcium• 0147T Computed Tomography angiography ofcoronary arteries (including native andanomalous coronary arteries, coronary bypassgrafts), with quantitative evaluation of coronarycalcium(effective Jan 1, 2006)

Optimal Report Generation•Indication•Clinical History•Procedure•Findings•Impression

Calcium Score01­1011­100101­400Over 400InterpretationNo identifiable atherosclerotic plaque.Very low cardiovascular disease risk.Less than 5% chance of presence ofcoronary artery disease.A Negative Examination.Minimal plaque burden.Significant coronary artery disease veryunlikely.Mild plaque burden.Likely mild or minimal coronarystenosis.Moderate plaque burden.Moderate non­obstructive coronaryartery disease highly likely.Extensive plaque burden.High likelihood of at least onesignificant coronary stenosis (>50%diameter).

New Category III CPT Codes for CoronaryCTA• 0146T Computed Tomography angiography ofcoronary arteries (including native andanomalous coronary arteries, coronary bypassgrafts), without quantitative evaluation ofcoronary calcium• 0147T Computed Tomography angiography ofcoronary arteries (including native andanomalous coronary arteries, coronary bypassgrafts), with quantitative evaluation of coronarycalcium(effective Jan 1, 2006)

Subjective Evaluation using MPRThere is a mixed nonobstructive(50%) non­calcified plaque andis a bifurcating vessel. Mid LADhas small nonobstructive mixedplaques. Distal LAD is normal.

Quantitative Analysis Using CMPR

Sample Report for 0146T

Final Impression:1. Normal Study2. Mild Disease (

Cardiac Incidental FindingsControversial Topic: Many Radiologists prefer Cardiologyinput.

Anomalous Coronary ArteryCurved MPR View of the Left Main from RCA3DVRT View of the RCA from the Left MainPoon M, Nat Clin Pract Cardiovasc Med. 2006 May;3(5):265­75. Review

DOT Sign

The Prevalence of Anomalous Origin of Coronary Artery: A Multi­Center Study†Zeng Y, ‡Mendelsohn SL, Karimjee N, ‡Day R, †Poon M†Cabrini Medical Center, New York, NY, ‡Zwanger­Pesiri Radiology, E. Setauket, NY, Life Imaging, Huntsville, TXBACKGROUNDRESULTSRESULTSReported incidence of coronary artery anomalies varybetween 0.4% and 0.8% in angiographic studies and 0.3% inan autopsy series. MDCT is evolving rapidly as a noninvasiveimaging method of choice for the evaluation of coronaryanomaly; however the frequency of such finding has not beenreported in MDCT studies. We aimed to investigate theprevalence of anomalous origin of coronary artery in threediagnostic imaging centers.LM from right sinus between AOand LALM from right sinus between AOand PALCX from right sinusRCA from left sinus0.06%0.03%0.32%0.23%LM­I29%RCA1150%LM­II15%LCX836%Left circumflex (LCX) coronary artery from right coronary sinusTotal0.64%METHODSA retrospective chart review of a 3356 patient registry fromthree diagnostic imaging centers in the United States (2 fromNew York and one from Texas). 2007 patients from CabriniMedical Center, NY; 584 from Life Imagine, Texas; and 765patients from Zwanger­Pesiri Radiology groups, New York.All patients were referred for the evaluation of suspected orknown coronary artery disease on a 16­, 64­, or 128­sliceMDCT scanner.Left main (LM) coronary artery from right coronary sinus­ Anomalous LM courses between ascending aorta and pulmonary arteryRight coronary (RCA) artery from right coronary sinusRESULTS22 patients (0.66%) with anomalous origin of coronary arteryincluding: anomalous origin of the left circumflex coronaryartery from right coronary sinus which courses anteriorlybetween ascending aorta and left atrium (n=11, 0.32%);anomalous origin of right coronary artery from left coronarysinus which travels posteriorly between the ascending aortaand right ventricular outflow tract (n=8, 0.23%); anomalousorigin of left main coronary artery from right coronary sinuswhich courses anteriorly between ascending aorta and leftatrium (n=2, 0.06%) or courses between ascending aorta andpulmonary artery (n=1, 0.03%).­ Anomalous LM courses between ascending aorta and left atriumCONCLUSIONSAdult anomalous origins of coronary artery are not verycommon and are usually incidental findings of diagnosticcatheterization or MDCT studies. Among the various anomaliesof the origin, left circumflex coronary artery anomalies are themost frequent (50 %), followed by the right coronary artery (36%) and the left main coronary artery (14%). Anomalous originof coronary artery that courses between the great vessels isassociated with the risks of syncope, myocardial ischemia andsudden death. MDCT may emerge as the imaging modality ofchoice for the evaluation of such coronary anomaly.

Kawasaki’s Disease

AV FistulaConus br to Anterior Cardiac VeinLM to PA

Giant Coronary Aneurysm

ASD

Double Chambered LVSanz J, Rius T, Kuschnir P, Macalusa F, Fuster V, Poon M. Circulation 2004

Non­Cardiac Incidental FindingsControversial Topic: Majority of Cardiologists prefer Radiology Over­read.

The Prevalence and Significance of Incidental FindingsDuring Cardiac 64­ or 128­ Slice Computed TomographyDinh 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. ‡Zwanger­Pesiri Radiology,BACKGROUND•The number of outpatient private practicefacilities offering multi­row detector computedtomography (MDCT) is on the rise.•Non­cardiac pathology may be imaged andmissed if not routinely assessed by theinterpreting physician.•Few studies have looked at the prevalence ofextracardiac incidental findings at outpatientfacilities.PURPOSE AND HYPOTHESISWe investigated the frequency and significance ofincidental findings during cardiac MDCT.MATERIALS AND METHODSA total of 512 consecutive patients underwent 64­or 128­slice MDCT (440 and 72, respectively)between the period of September 2005 to March2007 at two out­patient private practices.Radiology and cardiology final reports werereviewed for incidental findings, which weredefined as non­cardiac diagnoses not previouslyknown. Findings of clinical significance weredefined as those requiring follow up diagnosticimaging or intervention.RESULTSA total of 575 new, extra­cardiac findings wereidentified. Of this, 187 (33%) were clinicallysignificant. Per patient analysis showed that 117(23%) of patients had at least one new clinicallysignificant finding. The prevalence of allincidental findings, significant clinical findings,and specific significant incidental findings aresummarized in the table below.N = 511PulmonaryVascularHepaticGastrointestinalThyroidAdrenalOrthopedicOtherIncidentalFindings(No.Patients,%)189 (37%)105 (21%)61 (12%)41 (8%)25 (5%)22 (4%)9 (2%)47 (9%)E. Setauket, NY, USA.ClinicallySignificantIncidentalFindings(No.Patients,%)48 (9%)15 (3%)3 (0.6%)3 (0.4%)25 (5%)21 (4%)1 (0.2%)4 (0.8%)Clinically Significant Diagnoses(No. lesions)•Nodule/granuloma (>1cm) ­83•Cavitated granuloma ­1•Mass (1cm) ­14•Metastatic cancer ­1•Pulmonary embolus ­1•Ascending aorta aneurysm ­8•Descending aorta aneurysm ­3•Aortic arch aneurysm ­1•Type B dissection ­1•Splenic artery aneurysm (>1.5 cm) ­3•Celiac artery aneurysm (>1.5 cm) ­3•Mass 3.5 cm ­1•Lesions (not cysts) ­2•Hiatal hernia (entire stomach inthorax) ­1•Mesenteric lymph node >1.5 cm ­1•Pancreatic necrosis/fat/atrophy ­2•Thyromegaly ­3•Lesion/mass/nodule ­22•Adenoma (>1cm) ­19•Nodule (>1cm) ­1•Myelolipoma ­1•Sclerosis vertebral body/mets ­1•Angiomyolipoma ­1•Breast calcification ­1•Breast soft density ­1•Axillary lymph node ­1EXAMPLES OF INCIDENTAL FINDINGSCONCLUSIONSOutpatient private practice per patient prevalence ofclinically significant non­cardiac incidental findings isabout 23% during coronary MDCT examinations which issimilar to published data at academic centers and inpatientsettings. Review of all imaging data is important to avoidmissing potentially treatable disease.

SCCT Action ItemQuality Task Force: Dr. W. Guy WeigoldCardiac CT Data Elements and StandardizedReporting: Dr. Gil Raff

WWW.SCCT.ORG

New Category III CPT Codes for CoronaryCTA•+0151T Computed tomography, heart,without contrast material followed bycontrast material(s) and furthersections, including cardiac gating and3D image post processing; functionevaluation (left and right ventricularfunction, ejection fraction andsegmental wall motion)(effective Jan 1, 2006)

CT Evaluation of Cardiac FunctionASSESSMENT OF LEFT AND RIGHT VENTRICULAR FUNCTION WITH MULTI­DETECTOR 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,Ph.D., Valentin Fuster, M.D., Ph.D. , Michael Poon, M.D. 2006

CT function: Left VentricleA B CSimultaneous and automatic displays of 3 multiplanarreconstructions of the left ventricle in end­systole generated by thecardiac volume analysis softwareFigure A: Long­axis four chamber view of LVESV.Figure B: Long­axis two chamber view of LVESVFigure C: Short axis view of LVESV

CT function: Right VentricleA B CSimultaneous and automatic displays of 3 multiplanar reconstructions of the rightventricle in end­systole generated by the cardiac volume analysis softwareFigure A: Long­axis four chamber view of RVESV.Figure B: Long­axis two chamber view of RVESVFigure 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