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[Your institution’s letterhead][Today’s date]Seema Verma, AdministratorCenters for Medicare & Medicaid ServicesDepartment of Health and Human ServicesAttention: CMS - 1736-PPO Box 8013Baltimore, MD 21244-1850Re: CMS - 1736-P: Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs (CY2021)Comments submitted electronically via Administrator Verma: I am a [cardiologist/radiologist/hospital administrator/other] from [institution, location]. I appreciate the opportunity to comment on the CY 2021 Medicare Hospital Outpatient Prospective Payment System proposed rule. I am providing this comment in opposition to the proposed rule pertaining to CPT codes 75572, 75573 and 75574. The CY 2021 proposed rule continues a disturbing downward trend in reimbursement for cardiac CT angiography. For the fourth consecutive year, reimbursement for cardiac CT angiography has decreased (by 30% for 75574). Even more concerning is that these cuts exacerbate the fact that in the 10 years that CCTA has had a category 1 code, payment has never been sufficient to cover the cost of this test. Clinical practice guidelines published in the US and Europe continue to recommend CCTA as the preferred test in symptomatic patients without known coronary artery disease (CAD) with low to intermediate pretest risk. National scientific conferences through the American College of Cardiology, Society for Cardiovascular Computed Tomography, and others espouse the benefits of a front-line CCTA strategy. These recommendations are founded in a decade’s worth of strong prospective, randomized clinical data demonstrating CCTA is an accurate, cost-effective, safe, and prognostic test. In fact, multiple prospective studies have consistently shown that CCTA is associated with a 30-40% reduction in myocardial infarction and cardiac related death. CCTA is the only diagnostic test to show benefits in hard cardiac outcomes. Additionally, analysis performed in the UK as well as on US populations show CCTA can significantly reduce layered testing, normal invasive coronary angiography rates, and reduce unnecessary revascularization. These effects could have a tremendous cost savings to the US healthcare system. Beyond strategic advantages and system-wide cost savings, CCTA provides unmatched diagnostic certainty to the treating clinician. The ability to directly visualize the presence and extent of atherosclerosis significantly improves the confidence of an angina diagnosis. Furthermore, there is an unmatched warranty period of up to 7 years in patients with normal CCTA allowing for safe deferral of additional cardiac testing in this common subset of chest pain patients.Clinicians ultimately want to offer our patients the best possible care and technology available to us for the betterment of their care. However, we have to work within a larger hospital system in most cases. As such, it continues to be exceedingly difficult to justify continued low-level utilization of CCTA, let alone expanded access, when the current reimbursement rate does not cover the cost of providing this test. CCTA is a modality that has demonstrated equivalent diagnostic performance across gender, ethnicity, and age. The same cannot be said for other testing strategies for CAD. With further cuts to reimbursement rates, regional, community and rural hospitals that are already struggling under the continued cuts in reimbursement will be forced to stop offering this powerful service altogether. This will disproportionately affect certain geographic locations in which CCTA access is not mandated for training TA is should be reimbursed at a rate on par with other clinically and resource similar tests for CAD. CCTA requires hemodynamic monitoring equipment before and after scan acquisition. It requires extra nursing resources for administration of and monitoring after administration of vasoactive medications. It requires a specially trained CT technologist to protocol the scan and make on-the-fly decisions in order to maximize image quality while minimizing radiation and contrast dose. It requires specialized scanners to obtain freeze-motion pictures of coronary arteries at various heart rates and patient body habitus parameters. It requires specialized workstations and PACS systems to post-process and reconstruct the data sets. Additionally, the thin slice acquisition and multiple cardiac phases reconstructed require a tremendous amount of PACS storage space. These numerous requirements are much more in line with the facility and systems requirements to perform nuclear, MRI, and echocardiography stress testing and clearly require orders of magnitude more time, personnel, expertise, and specialized equipment than a contrast-enhanced chest CT. I stand with the Society of Cardiovascular Computed Tomography (SCCT), American College of Cardiology (ACC), and American College of Radiology (ACR) in requesting CMS to take immediate action to improve reimbursement to a level that better reflects the actual cost of providing this test. Action by CMS will allow hospitals and clinicians to expand capability and access to this valuable test in line with guidelines and value-based care. Thank you for your consideration of these issues. Sincerely,[Your signature] ................
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