Good afternoon, everyone. We're going to just give everyone a minute to log in. All right, we are going to go ahead and get started. Our topic this afternoon is CCTA, FFRCT, and plaque analysis, focusing on the revenue code and reimbursement optimization for your programs. I'm happy to be hosting the webinar with SCCT, the Society of Cardiovascular Computed Tomography. We're going to get started with a couple of logistics. So to start off, the handout will be available. There will be a link in the chat box that you are able to download these and save them as a PDF. Also, they'll be posted on our Academy website once the webinar is complete, along with the recording. If you have questions throughout the presentation, you can type those in the Q&A box. We will answer those either in the Q&A box directly. We should have some time for questions at the end, and if you ask questions and we don't get to them, we do respond after the webcast. Also, we'll ask that you keep your questions on topic around CCTA and your programs. So I'm happy to be joined by Dr. Mark Rabat. Dr. Rabat is the professor of medicine and radiology in the division of cardiology. He is the program director of Advanced Cardiac Imaging Fellowship at Loyola University in Chicago. He previously served as the chair of SCCT's Health Policy and Practice Committee and is dedicated to promoting evidence-based approaches to imaging, reimbursement, and quality care. He also was a key contributor to SCCT's efforts to achieve more appropriate reimbursement for cardiac CT through our Ops APC assignments, which we'll talk about. Many of you know me. I am Nicole Knight. I lead our Revenue Cycle Division at MedAxiom and executive vice president of the Care Transformation Team, also joined by my colleague, Jamie Warren, who is vice president of Care Transformation and our imaging guru at MedAxiom, and then also by Cara, who is the senior vice president of Marketing Access and Reimbursement at HeartFlow. So with that, I'm going to turn it over to Dr. Rabat. We have a couple of disclosures here, and Dr. Rabat, thanks for joining us. Thank you so much, and good afternoon, everyone. I'm Dr. Mark Rabat, and it's a pleasure to have you on today's webinar, which addresses the evolving landscape of cardiovascular imaging reimbursement. As a board-certified cardiac imager, professor of cardiology, and director of cardiac imaging at Loyola University of Chicago, I've had the pleasure of witnessing firsthand the transformative impact of advanced imaging technologies on patient care. Now, today's discussion is particularly timely, given the recent updates from the Centers for Medicare and Medicaid Services, or CMS, that have significant implications for how we approach CCTA, FFRCT, and AI-CPA, or plaque analysis in clinical practice. So as a leader of the Society of Cardiovascular CT Advocacy Committee and immediate past chair of the Health Policy and Practice Committee of SCCT, I've worked very closely with many SCCT members, as well as staff and other stakeholders, to elevate CCTA payment issues to Medicare, which ultimately led to the positive changes in reimbursement we are going to discuss today. These changes not only affect reimbursement, but also influence how we integrate these technologies into our diagnostic, as well as our treatment pathways. Now, today, I'm joined by esteemed colleagues, Nicole Knight and Jamie Warren from MedAxium, and Cara Santilla from HeartFlow, who will bring a wealth of expertise in revenue integrity, professional strategy, and clinical implementation. For this webinar, we're going to delve into reimbursement updates and recommendations for CCTA, or 75574, FFRCT, 75580, and AI-CPA, 0623T to 0626T. Now, before we do that, I thought it would be helpful to define the CCTA and AI diagnostics pathway. On this slide, you'll see the three currently available tests, which, as we discussed, are CCTA, FFRCT, and AI-CPA. Next slide, please. Thank you. I wanted to walk through the process by which a patient with stable chest pain goes through this pathway. The referring healthcare provider places the order. The patient's CT is then acquired, and cloud-based AI analyses are performed. Now, if a stenosis is identified in the 40% to 90% reduction range, FFRCT would be performed to determine the functional significance of that lesion. And if a patient was found to have evidence of CAD-RADS level 1, 2, or 3 disease, greater than 1% and less than 70% stenosis, then AI-CPA is performed. The reports are delivered to the physician, and then a precise diagnosis and a comprehensive treatment plan is undertaken. Now, as you can see, optimal diagnostic tools lead to better outcomes for patients. To support this level of quality care, the operational and financial components also need to be optimized. Our goal today is to provide you with these actionable insights that will help you navigate these changes effectively, ensuring that your institutions can continue to deliver high-quality patient-centered care while maintaining financial sustainability. Thank you again for joining us, and now I'm going to hand this off to Nicole Knight and then Cara Santillo to review the details. Thank you so much. So as an overview, we talked about what we're covering today. We're really going to focus on that Ops Reimbursement Update, some Revenue Code Updates, and then implications for that rate setting for our outpatient hospital payment system. Then we'll have some summary and action items. When we talk about the hospital outpatient update, when you look at 24 as compared to 25 in the final rule, CMS moved Cardiac CTA to APC 5572 and 25. This resulted in a change in about 104%, which is significant. When you look at FFRCT, and this is all FFRCT, it is paid under APC 5724. That resulted in a payment increase of 2%. Now for our AI plaque analysis, it is assigned to that new technology APC and reimbursed at a rate of $950. This appropriately reflects the value of our CCTA that provides us the care for our patients and the pathway. So I think it's important to note what's been achieved over time in this space and to ensure that you are looking at your charge master correctly. Those are the things you'll hear us repeating as we go through what are those Revenue Code Updates and considerations. So Medicare CMS allows health systems to choose the appropriate Revenue Code for the service that they're providing. So what happened, you know, when you look at specific Revenue Codes for CCTA and FFRCT, there were some updates that had happened because they were originally under cardiology. Then there was some guidance, and Cara's going to take us through that pathway about radiology Revenue Codes. But this is just to tell you, when you look at your charge master, and we have the references here as well, connect with your, if it's your supply chain, if it's your charge master, and determine what are the current Revenue Codes you are billing for CCTA, FFRCT, and your AI, because if you're not doing the cardiology codes, we're going to emphasize what that impact is, what that looks like now and in the future. So I'm going to turn it over to Cara, who's going to take us through that pathway and the restrictions that we faced. Thank you, Nicole, and thank you, Dr. Rabat. And you know, we're going to kick off and get started with the understanding of Revenue Codes for CCTA. And I really have to say thank you to Dr. Rabat and the physician leadership at SECT as well as the staff, because there has been a multi-year effort there to support CTA reimbursement. And it really came down to their sustained effort and working through the nitty-gritty of Revenue Code updates to allow for a really positive change. And one of the reasons why we wanted to go through this in detail today was really to highlight that work, but then also the action that is needed to really understand how to make these changes sustainable for the long-term support of the CCTA pathway. And you know, we're going to ground ourselves a little bit in the work that SECT did, and then move through the recommendations, and after each section, we're going to have some action items for your consideration for updating your system. And so, just to kick this off, you know, part of that sustained effort that SECT undertook in working with CMS was to understand kind of what was going on in the CMS ecosystem pertaining to all of the inputs for CCTA reimbursement. And one of the things that was noted was that for years, CMS had put a Revenue Code restriction in front of the CCTA CPT Code 75572, 75573, and 75574, so that when a Revenue Code that was not a radiology Revenue Code was used, there was an error, and it was returned to the provider, the claim was returned to the provider, saying that this was not a billable claim and they needed to make changes and change the Revenue Code. This ultimately suppressed the overall charge, cost-to-charge ratio, and average cost of the service into CMS. This was highlighted to CMS Federal that this edit existed, and at the end of 2023, CMS released this MedLearn Matters article saying that they had removed that Revenue Code restriction and that appropriate Revenue Codes may be billed with CCTA. SECT also highlighted this change in several of their notifications and really provided a little more color stating that now the opportunity to bill the cardiology Revenue Codes, which is what Nicole just showed, is now available for CCTA. The CMS restrictions have been listed, and those would be the most appropriate Revenue Codes to bill. Next slide, please. So when we really look at this timing, before 2024, sites had to submit claims using the radiology or CT Revenue Codes. Once CMS released and removed those restrictions, starting in 2024, sites could use the cardiology Revenue Codes or any other Revenue Code that they deemed appropriate to be associated with the CCTA service. In the proposed rule, which came out in July of 2024, CMS took a unique step to really understand and promote CCTA reimbursement, and what they said was that if more than 50% of hospital departments use the cardiology Revenue Codes, they would move CCTA to a higher-paying APC or up one level from 7521 to 22, and whenever they moved that, excuse me, 5721 to 5722. So that's an APC uplift. And when they talked about doing that, that was in the comments of, they asked for comments on this in the proposed rule. And from what I've heard from both SECT and CMS staffers, they received a significant number of comments saying that, yes, sites would move to the cardiology Revenue Codes for CCTA. CMS then took the step to finalize that increase of that APC in the final rule for 2025. So in November, they said, we received enough comments to say that sites would be using the cardiology Revenue Codes. We are going to increase that APC or go up one level of that APC. And if you go to the next slide, that was actually finalized in the final rule. But in order to make that sustainable and really support CCTA reimbursement, the call to action is to review your Revenue Code assignment for CCTA and update to that cardiology Revenue Code when appropriate. And then also, given that there has been a change in reimbursement, where it doubled in for 2025, take another look at your CCTA-related charges. The new reimbursement really reflects what those technical charges are that are associated with CCTA. So it's a dual call to action, where review your Revenue Codes and then look at your charges. Next slide. So from there, we're going to venture into the world of FFRCT, or as those of us in the reimbursement world know it as, 75580. And this story is going to sound shockingly familiar to those who were paying attention to the previous slide, so no need for a long attention span here. There's a similar Revenue Code issue with FFRCT, where in 2023, FFRCT had Category 3 or C codes. But when the service converted to a Category 1 code, 75580, which happened on January 1, 2024, the Medicare administrative contractors put similar edits in front of FFRCT that they had previously had with CCTA to require the use of the radiology revenue codes. And this was not published anywhere. This was not really made public. It wasn't part of the conversion. And so when sites submitted their claims using the cardiology codes, which they had all historically been using, those very similar return-to-provider edits that they had seen with CCTA also hit for FFRCT, and they were required to resubmit those claims using the radiology revenue codes. And in response, that forced many hospitals to flip to the radiology revenue codes for 2024 in order to get those claims submitted and paid. This came to our attention, and we worked with SECT and many of the sites, if you go to the next slide, and many sites to really bring this to the attention of CMS to say that these revenue code restrictions that had never been in place previously were now in front of FFRCT. When we went to the CMS Division of Outpatient Care and brought this to their attention, they then removed those revenue code restrictions from in front of FFRCT and put out, this will look very similar. So this was released in late September of 2024, saying that they had since removed the revenue code restrictions that the MACs had put into place and that appropriate revenue codes may be released, may be used with FFRCT, and that if there were any denied claims or claims that were forced to be submitted using the radiology revenue codes, that those could be resubmitted with the cardiology revenue codes. So there was a MedLearn Matters article as well on this very same issue, very similar to CCTA. So the radiology revenue code restriction was an error on the part of the MACs. It was not supposed to be in place to begin with. Next slide. And, you know, to really drive this point home, we did a little analysis. And in 2023, 79% of sites submitted claims using the cardiology revenue code for FFRCT to CMS. When CMS, when the MACs put that revenue code restriction in front of FFRCT, through the first three quarters of 2024, only 4% of sites were using that cardiology revenue code, showing, you know, that there was a significant decline, even though that was an error. And this really does have long-term ramifications, where the data going into CMS now using, looking at the FFRCT with the cardiology revenue codes, it really impacts the geometric mean costs. And that impact, based on an error, can lower reimbursement up to 50% moving forward. It also may have implications for your commercial payer contracts. There are some commercial payer contracts that do use revenue codes and cost-to-charge ratios as part of the payment algorithm. And so updating those revenue codes could also have a material difference on your commercial payer contracts. Next slide, please. So, again, the call to action is very similar. We like to keep similar themes to make this easy. When you are looking at your revenue code assignments for FFRCT, please also consider using the cardiology revenue codes when appropriate. And then also, if you have any of those claims from the first three quarters of 2024, please look and see if those may be resubmitted using the cardiology revenue codes. There may be, that would also help support future reimbursement. And there may be some updates there. So, again, for FFRCT, review the appropriate revenue codes, use cardiology revenue codes when appropriate, and then resubmit any of those returned claims with the appropriate revenue code. Next slide. All right, so we're going to move into new technology world here. So, CTA and FFRCT are established services. But AICPA, or AI Coronary Plaque Analysis, so you're going to hear multiple terms for this. So we call it plaque analysis, AI plaque analysis, or AICPA. Those terms all refer to all the technologies and services that fall under the AI plaque analysis umbrella. Currently, that's CPT code 0623T through 0626T. And the reason why this is interesting is in December of 2024, so December of last year, five of the seven MACs finalized and made effective coverage for AICPA. And you can see the coverage criteria here. And Dr. Rabat did a nice job in the intro kind of reviewing what that is. But at a high level, the patient is eligible for CCTA, so stable chest pain patient presents with acute or stable chest pain and is at intermediate risk for CAD and or has CADRADS 1 through 3 level disease that's roughly more than 1 to less than 70% stenosis and is negative or inconclusive for acute coronary syndrome. So that coverage criteria is in effect for all of the states that are in the dark purple or blue. All of those MACs currently have effective positive coverage policies for AICPA. And then the Medicare Advantage plans in those states also cover as well. In the lighter purple states, we are seeing case-by-case coverage for AI plaque analysis as well. And those MACs are Novitas and First Coast. There is an additional evidence package requirement whenever you are submitting. But there is coverage there as well. So next slide, please. And just another update on plaque analysis, AICPA. The four category 3 codes that you do see today, so the 0623T is the global code that's used in the physician office setting. 0624T and 0625T are technical codes in the hospital outpatient. And 0626T is the professional code in the hospital outpatient. Those will be available through the rest of 2025. Starting on January 1, 2026, a new category 1 code will be in effect. Currently, we know it as 75XX6. We will learn in September when AMA releases the CPT book that full final descriptor as well as what those XX looks like. And the modifiers, there will be modifiers in the hospital to note TC and 26 likely available. So that'll happen on January 1. So the rest of this year, the T codes are in effect. And then through January 1, you'll see those T codes will sunset. And then the category 1 code will come into place. Next slide. So very similarly to CTA and FFRCT, as you are considering setting up your revenue integrity revenue cycle systems for AICPA, it is appropriate to use those cardiology revenue codes for the entire CTA pathway. So for CTA, FFRCT, and plaque analysis. So for all three of those, utilizing that revenue code, the cardiology revenue codes is appropriate. So as the reimbursement evolution occurs for AICPA like what we saw with FFRCT, think through appropriate revenue code assignment there as well. Next slide. All right. Now we're going to take a very quick and I promise hopefully painless journey through policy wonk land to really understand why are we making these recommendations and what other practical considerations may you have when you're thinking through revenue code assignment, charges, charge master, and when to make these updates. So I'm going to use throughout this section either CTA or FFRCT as an example for what you're thinking through for practical considerations. I think it's helpful to ground in what does CMS really look at when they're thinking through how do rates get set year over year? What data are they looking at? What is that process? So we're just going to start with these FFRCT codes. A hospital will start and they look at revenue code assignment which we had talked about previously. Those revenue codes are then mapped to cost center which are assigned to, noted on the cost report. That cost center has a cost to charge ratio which is used to calculate the costs. The facility then establishes a charge which is based on fair market value. We'll get into that a little bit more in detail which is put on the charge master. That cost calculation using the CCR and the average facility charge is reported into CMS. And CMS uses that to calculate the national average cost. They use single frequency claims or claims that don't really have other services on them. They calculate that national average cost. That national average cost is then used to crosswalk, is for that service is assigned to an APC. And if that national average cost supports the resource use in that APC, it kind of remains in the APC bucket. But if that cost comes down, there may be an additional APC assignment. And so really, it all starts with appropriate revenue codes and charge assignments to allow for supporting of reimbursement moving forward. Keep in mind that CMS, when they're doing, when they're looking at all of this data, there's a two-year lag. So CMS currently is looking at 2024 data to assign rates for 2026. Next slide, please. Now, one thing to keep in mind for some considerations when you're thinking through a revenue code and cost-to-charge ratio assignment, CMS uses single frequency claims, like I mentioned before, whenever they're looking at setting those national or doing the calculation for those national average costs. And if you use CCTA as the example, if you assign CCTA the cardiology revenue codes, then an appropriate cost-to-charge ratio is applied. One of the recommendations is to really look at, make sure that there's a fair market value of that service assigned for your charge master, and then that rate is then published on the charge master. And some other practical considerations, just digging into this. If you're thinking about kind of what does that gross charge look like, that does vary by service, and it's based on what is considered to be fair market value for the service. And then it is important to note that, you know, that data does change on a year-over-year basis. And it's, you know, when you're thinking about CCTA in particular, you know, one of the arguments with engaging with CMS is, you know, that revenue code restriction that they had put in front of CCTA was really depressing and masking what the actual costs were to provide a CCTA. And CMS agreed with that argument when they reviewed, whenever they reviewed and removed those revenue code restrictions. So it's important to, on an annual basis, or when new technology becomes available, really look at what is a fair market rate for that service when you're setting the gross charge. And I would particularly say for, at this point, for CCTA, you know, when your next annual review comes up, take a look at that based on, you know, the new reimbursement and other things that it costs, other ways it costs to provide that CCTA service. For revenue coding, you know, we've talked extensively in this webinar about those restrictions being removed for CCTA and FFRCT. Recommendation is moving forward with those cardiology revenue codes. And then ensuring that an appropriate cost-to-charge ratio is assigned based on the revenue code that you choose. Next slide. And, you know, I would be remiss if I didn't show an example and do a little bit of math. So the table, and I apologize for the font, but the table that you see here is, this is data directly from the OPPS. This is publicly available data from OPPS, from CMS, looking at, you know, various large centers across the U.S. And in 2023, this is, we used FFR as the example here. In 2023, you know, they all had revenue codes assigned using the cardiology revenue code. And then in 2024, when that revenue code restriction was put into place by the MACs, they all flipped to the radiology revenue codes in order to get the claims through. And this table really shows you the math of, you know, when that flip occurred, what does that actually mean from the claims single, and what you're really going to look for is the claims average cost adjustment to show what the average cost of that service that CMS now takes into consideration. And it really, you know, it really reduced from 2023 when the cardiology revenue codes were used to 2024. And the one thing to point out here is that you don't see a reduction immediately in your Medicare reimbursement because they're on a two-year lag. What those revenue code utilization does is having appropriate revenue codes assigned supports future reimbursement for the service. So that's why I just wanted to show in using publicly available data that's available from CMS kind of what that actually means from the data that CMS ingests to make those year-over-year or those yearly rate-setting determinations. They really do look at the single-frequency claim data and what cost-to-charge ratios are used and what average charge is assigned. And on the bottom here, we just put sort of, if you're thinking through, you know, for the various CPT codes we talked about today, CTA, FFR, plaque analysis, kind of what revenue codes you should consider, where that would be mapped, and then, you know, we have an average charge, and if there's the CCR for most cardiology codes is above, you know, 18, 20, 25 percent, you know, if your CCR is appropriate, then what your, this, we used FFRCT for that example, kind of what your cost calculation should really come out to look like. And so I hope this was helpful in kind of explaining both revenue code assignment, all the great work SCCT has done to really elevate this issue, and support future reimbursement for the services on the CCTA pathway. So with that, I'm going to hand it over to Nicole to wrap us up, and we can take some questions. All right, thanks so much, Kira. So just a summary, and a few action items, and just kind of repeating, be sure, you know, we are talking on the facility side of things. Make sure that you are verifying your revenue codes, and I think the biggest message, not only do we have claims data that lags behind, that CMS is looking at, this is also what you use to determine our future reimbursement. So, you know, you have this data that's lagging behind, and this is determining reimbursement. So really, in your health system, who is doing this work? What does that look like for your programs? Particularly when, such as the AICPA will start with a temporary code, and thank goodness we're getting a CPT code, but, you know, you have to pull that data in your systems to look at what that looked like before the CPT code was established, and then now that you have a CPT code, or when we do next year, that you are comparing that data, because when you look at that as a program, you want to be sure that you're aligned across your system. So what can we do? You want to select that appropriate revenue code. You want to set your gross charge that's reflective of the services you're providing, and again, look at that cost to charge ratio for the appropriate cost center and the mapping for that. A lot of this lies within your charge master departments. Many of our CV service line leaders across MedAxiom, I know, have this information and deliver it to the right person. I think it's key to be able to get this information to your right member of your staff so that we know what data we're getting looked at and how this rating is being set for our future. I will say we'll dive into questions a little bit, and I know a lot of our questions, or a couple of our first questions, were around our professional service side. So when you look at the physician fee schedule and the differences in the physician fee schedule versus what happened in the ops hospital outpatient department, we only saw a minimal increase on that physician side of services. That is mainly due to how the methodology is calculated by the two different entities. It is all CMS, but they're done differently, and we saw that we know our conversion factors have been hit, work RVUs, all those things that go into the calculation on professional services, which is why we don't see that significant impact on the physician service side because it's two totally different methodologies. Dr. Rabat, I'll kind of ping you from an advocacy perspective. I'm curious, or just in general, how the professional service side is being addressed. I think that's the questions we're seeing. I know in working with the ACC and other entities and organizations, obviously, their advocacy efforts always include our advanced imaging. Yeah, Nicole, so there's ongoing efforts with both CMS and even congressional efforts for that matter trying to address this issue. Kara, perhaps you would have some additional insight on your end? Yeah. There's a large-scale effort to further support CCTA reimbursement on the professional side as well as in the global rate in the freestanding imaging center. As Nicole said, the rate-setting algorithm that is used in the Medicare physician fee schedule is very different from the hospital outpatient. I'm not saying better or worse, very different. A lot of those, that global rate in particular, is tied to the RVUs and conversion factor associated with the CCTA service. There's a lot of discussions for CCTA in specific, but also in general in supporting particularly that conversion factor year over year to allow for sustainability and also increases to keep up with the cost of performing these services. I know there's a large-scale campaign with, I always like the term, House of Medicine, so the various houses that go into the House of Medicine to really support those efforts. And there's been discussion about maybe looking at various ways to support on the MPFS side of the physician fee schedule side, supporting further reimbursement efforts there. There's only a few levers that can be pulled, and I think they're all being explored at this time. There's no definitive path forward, but there is definitely a concerted advocacy effort. It's going to take a lot of voices in order to really support that conversion factor as well as update potential RVUs for CCTA. Absolutely. Thanks, Kara. If you hear, Kara, around cost centers and departments and staff allocation, I'm curious if the revenue codes, and they're being challenged on that because a lot of this information, as you know, from CMS, from other payers, it gets confusing. And then, of course, other systems don't necessarily update us timely. We have the whole Medicare Advantage piece. And my best advice to them is, please look at all of your reimbursement, your revenue codes across all of your multiple payers. Is there anything else you would suggest to these entities to be able to have and facilitate that conversation? I think it's really important to do at least an annual review of the appropriate revenue codes. And CMS, it's so interesting, you know, they see these revenue code restrictions and remove them and put out guidance in MedLearn Matters. It is written in CMS speak, and so it's not the clearest guidance ever. And so that's why we actually wanted to do this webinar and really talk through these issues because those revenue code restrictions were removed, but the take action piece does not come across in the education as clearly as it probably should. So my two recommendations really are, after this webinar, go back, look and review what revenue codes are assigned to CTA, FFR, and then if you're considering adding plaque analysis or AICPA. And, you know, if your revenue integrity person was not able to join this call, you know, please reach out, ask them, you know, what revenue codes are assigned. If there's pushback, you know, we're happy to have the conversation. And, you know, just because a specific revenue code is assigned does not mean that the accounting has to exactly follow that revenue code assignment. There's a cost accounting procedures many hospitals have to, you know, share revenue, and that looks a little bit different in every site, but I just want to handle that if that comes up as an objection as well. We have many sites that the unique juxtaposition between cardiology and radiology to provide services on the CCTA pathway does warrant a conversation of appropriate revenue code assignment. And then the second thing I would also add is, you know, take a look at your charges and make sure that they really reflect the fair market value so that your charge master is optimized year over year, especially with a lot of these changes coming through, because I think those two things together will really help ensure that you have an optimized system to be able to long-term provide, you know, high-quality cardiovascular diagnostic care. Yeah, and it is my experience as well in working with some charge master reviews and organizations that even though CT in a sense is under radiology, like you said, it warrants the conversation because you're not required to use the CT radiology revenue codes for the cardiology CTA. You can use the cardiology revenue codes and that's specifically what the guidance is telling us. So I think it does warrant a conversation and definitely something to look at. You know, again, when you're looking at revenue codes, CMS is pretty vague about and other payers I will tell you will say, well, we want you to use this revenue code or we want you to use that revenue code. So you want to have your information and those conversations are crucial. Jamie, I'm going to ask you from an imaging perspective and what you're seeing, do you see where for coronary CTA, FFR, and the AI piece that all three of those are being performed? Do you think, and I'll be interested to get Kara's thoughts and Dr. Rabat's, do we think we'll have bundling in that? Has that been talked about? We have a couple of questions about that because in our world, everything usually gets bundled together. So Jamie, what are you seeing in that imaging space? I would say that what we're finding is that it's not necessarily uniform across the different locations that we see in US and each one has different operational workflows when it comes to using the additional tools and being able to do CT. The bundling question, that's a tough one. And actually, I'm going to kick that to Kara and see what she would respond to that. I can confidently say in 2025 that CTA, FFRCT, and AICPA are all separately billable services. They all have, for those of us who follow the status indicators within CMS, they all have an S status indicator, meaning they are separate and distinct services. And so there is no bundling right now for any of those services. What happens in the future, I think we will see as payment policy for these services evolves, something may pop up and we'll deal with it. But as this really evolves and you're starting on the good work of CCTA reimbursement going up, I think CMS really understands the value of this service line in diagnosing cardiovascular disease and has allowed for all of these to be separately billable services. There is one note that I saw a couple questions on. For AICPA or plaque analysis, there is an NCCI edit that plaque analysis should be billed on a separate day from CCTA. So this is only for CCTA and AICPA. So the NCCI edit requires that the plaque analysis service be billed on a different day or the next day or not on the same date of service as the CCTA service. And so there are modifiers that may be available if you do want to bill it on the same date of service, that's up to your facility to consider. But that is the one edit in place. We are in discussions with CMS on the appropriateness of that edit and keeping it long term, hopefully not. But for this year, please note that just plaque analysis in order for separate payment to be allowed needs to be billed on a separate date of service from CCTA. Yes. And similar to our OPS facility payments for our physician service side, we have a few questions coming in for that. Those are separately reimbursed as well. And, you know, just like many of our advanced imaging modalities, it's important to bill those in order to look at those claim volumes and determine what those volumes are for that rate setting and what that looks like, even if it leads to some bundling, hopefully not in our future. But if it does lead to that, at least we have the right data going into this. We're using the right revenue codes. We're using the right gross charges to be able to get that information and adequately reflect that. Absolutely. Yeah, that's exactly right. Do you often see in organizations, and I'll throw this out there and see if you guys know the answer. If we don't, we can definitely put it out on our listserv as well. Do you see where some entities have one institution that is doing the CCTA portion and a different one that may be doing the FFR or AICPA portion of that? Or is it usually a combined effort? I really don't have much insight into that. It's typically the institution that does the CCTA also orders the FFRCT and or plaque analysis when appropriate. So it's usually done all in one facility. Yeah, that's what I usually see as well. Yeah. Okay. All right. Well, I think so with when we talk about revenue codes, those are specific to hospital facilities. So when you're looking at anything fee for service on that technical side, and if you're using the office setting, we have a few questions about that. Those revenue codes do not apply to that. So it does apply on your facility outpatient diagnostic services, which many of us do our diagnostic testing in an outpatient hospital facility. So just as a reminder. Okay. I think that we've gotten through most of the questions. We do appreciate everyone joining us today. And we definitely appreciate Kara and Dr. Rabat sharing time with Jamie and I on this topic as we continue to navigate our advanced imaging. We will have an email go out after, probably after the holiday. So hope everyone enjoys that long weekend. And it'll have a flyer that is kind of a call to action that you can share across your facilities and your institutions. And then also this will be available as a recording that you'll be able to share as well. So we appreciate your attendance and thank you all.

cardiovascular imaging

reimbursement strategies

CCTA

FFRCT

Medicare updates

revenue codes

CPT code changes

financial sustainability