Q&A: Contrast for Stress Echo

Adding contrast to stress echocardiography has been established as an effective method of improving Doppler signals and boosting image quality, but there have been recent changes to reimbursements and FDA warnings on the addition of contrast. Matt M. Umland, RDCS, FASE, a director on the board of the American Society of Echocardiography (ASE) who is from Milwaukee, and Diane Millman, counsel for the ASE in Washington, D.C., discussed the latest information on contrast enhanced stress echo.

What are the most common indications and patient populations for contrast stress echo?

 Umland:  The reason for using contrast enhanced imaging for  stress echocardiograms is to improve image quality. As far as the patient population, it varies depending on body habitus. Resting images are taken prior to the stress procedure, and at that time, image quality is assessed for visualization of left ventricular wall segments. Then a decision is made whether contrast would better enhance endocardial border definition, which is very important with stress echocardiogram. …The rule is, if you can’t see two contiguous LV [left ventricular] segments, that’s an indication for contrast usage.

Are there additional materials, time and costs?

 Umland:   The extra essentials needed for the procedure would be, of course, the contrast and then if there’s any IV insertion, or any additional insertion products. As far as the time, most of the stress echo patients have an IV inserted prior to the stress echo as a safety precaution in case there are any complications, so they have the IV access already initiated. In most cases, it’s just the additional contrast administration. Actually, the time generally is decreased with contrast utilization, because the sonographers performing the studies are not struggling quite as much. With the contrast enhanced imaging, it’s like taking a flashlight and shining the light; you are able to see the endocardial border much better with contrast in most cases.

Can you talk about reimbursement issues? Stress echo with contrast was reimbursed at a rate lower than unenhanced stress echo.

 Millman:  The reimbursement situation has changed this year so that, in fact, payment for stress echo with contrast is higher than unenhanced stress echo. That was remedied as a result of the new hospital outpatient payment rules for 2013. … In non-hospital settings, contrast itself is reimbursed separately as a drug and contrast administration is also paid under the Medicare program for stress echo. The contrast administration code for stress echo also may be recognized by private payers. In the hospital outpatient setting under Medicare, there’s a separate ambulatory payment classification for contrast enhanced stress or comprehensive resting echo, which is paid more than unenhanced echo.

What is the status of FDA warnings and contraindications?

 Umland:  [The FDA] had a black box warning with multiple contraindications for [contrast] usage. Since then, they have made revisions, but with a few contraindications for usage remaining. One is a cardiac shunt, and the other is, of course, hypersensitivity to contrast. Now they’ve really limited what was on that black box warning and from a "user" standpoint made it much easier to use and monitor.

Any closing comments on the overall use of contrast stress echo?

 Millman:  ASE strongly supports the use of contrast in appropriate cases to enhance images. The accreditation rules now require accredited labs to have the capability to administer contrast.

 Umland:  I agree completely. … When we look at reimbursement and total expenses for patients, we have to choose procedures that are best suited for them. We want to get the best quality that we can, and if indicated, contrast-enhanced imaging is putting us to that next level of giving them quality care and hopefully not having to go on to additional tests because of poor image quality.