Journal Club: May 2011

J Am Coll Radiol. 2011 Apr;8(4):235-41.

Expanding Utilization and Regional Coverage of Diagnostic CT Colonography: Early Medicare Claims Experience.

Duszak R Jr, Kim DH, Pickhardt PJ.


PURPOSE: The aim of this study was to assess national and regional trends in utilization and Medicare coverage of diagnostic CT colonography (CTC).

METHODS: Medicare claims for diagnostic CTC were identified for the first 4 complete years for which Current Procedural Terminology ® tracking codes existed (2005-2008). The frequencies of billed and denied services were extracted on a national and regional basis, along with physician provider specialty and site of service.

RESULTS: Total annual claims for diagnostic CTC for Medicare fee-for-service beneficiaries increased from 3,660 to 10,802 (+195%) between 2005 and 2008. Overall, 50.1% (14,051 of 28,048) of all claims were denied, with annual national denial rate decreasing from 70.0% to 43.4% (2,562 of 3,660 to 4,692 of 10,802, P < .001). Annual regional denial rates ranged from 16.5% to 98.3%. Of all 28,048 CTC claims, 25,893 (92.3%) were submitted by radiologists, 286 (1.0%) by gastroenterologists, and 369 (1.3%) by other specialists (specialties were indeterminate for 1,550). Most services were performed in office (n = 13,764 [49.1%]) and outpatient hospital (n = 12,110 [43.2%]) settings, with only a small number in the inpatient hospital (n = 1,768 [6.3%]) and other miscellaneous (n = 406 [1.4%]) settings.

CONCLUSIONS: Diagnostic CTC is performed predominantly by radiologists in private office and outpatient hospital settings. Since the advent of Current Procedural Terminology tracking codes, the utilization of diagnostic CTC by Medicare fee-for-service beneficiaries has tripled. Despite perceptions that new technology tracking codes are not payable, more than half of all examinations are now reimbursed by Medicare. Coverage varies regionally but overall is improving annually, setting the stage for expanded patient access.