HeartFlow’s CCTA Outpatient Reimbursement Increased by CMS

November 8, 2024—HeartFlow, Inc. recently announced that the Centers for Medicare & Medicaid Services (CMS) released a final rule elevating the ambulatory payment classification (APC) of coronary computed tomography angiography (CCTA). The final rule increases reimbursement from $175 to $357 for CCTA Hospital Outpatient Prospective Payment System (OPPS) services and increasing Physician Fee Schedule (PFS) global payment to $318, effective January 2025 for Medicare patients.

According to HeartFlow, the CMS decision was supported by a growing body of clinical evidence demonstrating the diagnostic test’s accuracy and efficiency and advocated for by a coalition of healthcare providers led by the Society of Cardiovascular Computed Tomography (SCCT). The company noted that these reimbursement increases align with CMS’ commitment to advance cardiac care and improve patient outcomes, making it more advantageous for institutions to adopt CCTA in the diagnosis and treatment of patients with coronary artery disease (CAD). Commercial payer payment rates for CCTA can range from $175 to $2,500.

HeartFlow stated that it encourages providers to collaborate with commercial payers to ensure their contracts reflect the updated CMS rates and the recognized value of CCTA in cardiac care.

“Physicians have increased the use of CCTA an average of 20% annually over the last 5 years,” commented Maros Ferencik, MD, in the HeartFlow press release. “This reimbursement reflects CMS’s recognition of the benefits CCTA offers, including superior imaging versus other noninvasive imaging modalities, efficient patient pathway guidance, and reductions in unnecessary tests.”

Dr. Ferencik, who is Professor of Medicine and Radiology and Section Head of Cardiovascular Imaging at Oregon Health & Sciences University in Portland, Oregon, serves as President of SCCT, continued, “This is an exciting step forward for healthcare providers. SCCT proudly supports this important increase in reimbursement to facilitate more accurate diagnosis and care for patients with cardiovascular disease.”

The company noted that from one single test, CCTA provides a comprehensive view of a patient’s CAD and guides treatment planning when combined with the HeartFlow fractional flow reserve computed tomography (FFRCT) and Plaque Analysis.

In addition to the CCTA rate increases, the CMS payment rate for the HeartFlow FFRCT Analysis is increasing from $997 to $1,017 for 2025 and the payment rate for Artificial Intelligence-Enabled Quantitative Plaque Analysis (AI-QPA) services including the HeartFlow Plaque Analysis will be set at $950. These reimbursement decisions better align financial incentives with clinical outcomes, empowering providers to leverage advanced imaging technologies for superior patient care, stated the company.

On October 15, SCCT announced that four of the seven Medicare Administrative Contractors (MACs) released final local coverage determinations (LCD) for artificial intelligence (AI) coronary plaque analysis (AI CPA). The LCDs for current procedural terminology (CPT) codes 0623T–0626T have an effective date of November 24, 2024. The four MACs are CGS, National Government Services, Palmetto GBA, and Wisconsin Physicians Service Insurance Corporation.

On October 18, HeartFlow announced the Category I CPT code, supporting access across the United States and recognizing the value and critical role of AI-enabled plaque quantification technologies in cardiovascular disease management. On October 24, HeartFlow announced that the LCDs for these four MACs plus a fifth, Noridian beginning December 8, will expand patient access across to HeartFlow Plaque. The coverage of HeartFlow Plaque Analysis extends to Medicare beneficiaries with acute or stable chest pain and < 70% stenosis found on CCTA.