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

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

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)

Report generation 1. Indication = ICD 9 code(s) Model LCD

ICD 9 CM

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. Evaluation of chest pain syndrome in patients with intermediate pre test probability of CAD. 2. Evaluation of acute chest pain in patients with intermediate pre test probability of CAD. 3. Evaluation of suspected coronary anomalies 4. Evaluation of chest pain syndrome in patients with uninterpretable or equivocal stress test. 5. Assessment of complex congenital heart disease including anomalies of coronaries, great vessels, and cardiac chambers and valves. 6. Evaluation of coronary arteries in patients with new onset heart failure to assess etiology. 7. Evaluation of cardiac mass 8. Evaluation of pericardial conditions 9. Evaluation of pulmonary vein anatomy prior to invasive radio frequency ablation for atrial fibrillation. 10. Non invasive coronary vein mapping prior to placement of biventricular pacemaker 11. 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 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)

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)

Calcium Score 0 1 10 11 100 101 400 Over 400 Interpretation No identifiable atherosclerotic plaque. Very low cardiovascular disease risk. Less than 5% chance of presence of coronary artery disease. A Negative Examination. Minimal plaque burden. Significant coronary artery disease very unlikely. Mild plaque burden. Likely mild or minimal coronary stenosis. Moderate plaque burden. Moderate non obstructive coronary artery disease highly likely. 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 RESULTS RESULTS 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. LM from right sinus between AO and LA LM from right sinus between AO and PA LCX from right sinus RCA from left sinus 0.06% 0.03% 0.32% 0.23% LM I 2 9% RCA 11 50% LM II 1 5% LCX 8 36% Left circumflex (LCX) coronary artery from right coronary sinus Total 0.64% METHODS A 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. Left main (LM) coronary artery from right coronary sinus Anomalous LM courses between ascending aorta and pulmonary artery 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

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, 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. 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 64 or 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. N = 511 Pulmonar y Vascular Hepatic Gastrointestinal Thyroid Adrenal Orthopedi c Other Incidental Findings (No. Patients, %) 189 (37%) 105 (21%) 61 (12%) 41 (8%) 25 (5%) 22 (4%) 9 (2%) 47 (9%) E. Setauket, NY, USA. Clinically Significa nt Incidenta l Findings (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) 1 Pleural thickening/plaques 10 Chest/mediastinal lymph nodes (>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 in thorax) 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 1 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, Ph.D., Valentin Fuster, M.D., Ph.D., Michael Poon, M.D. 2006

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