This spring SCAI earned Accreditation with. At the SCAI 2012 Scientific Sessions in Las Vegas, SCAI announced

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1 Summer 2012 LOOK INSIDE Highlights of SCAI 2012 Starting on page 8 The Society for Cardiovascular Angiography and Interventions SCAI Reaccredited by ACCME with Commendation Accolade SCAI leaders got the PAC off to a strong start with generous personal donations. SCAI Forms Political Action Committee to Strengthen the Voice of Interventional Cardiology in Government At the SCAI 2012 Scientific Sessions in Las Vegas, SCAI announced the formation of a political action committee (PAC), the latest step forward in the advocacy program established by the Society in the early 1990s. The decision was enthusiastically embraced by members attending SCAI 2012, evidenced as members stepped up to support the PAC. In just the few annual meeting days, more than $30,000 in contributions accumulated and enthusiastic members proudly sported PAC donor ribbons on their badges. The decision to establish a PAC may be the single most important decision SCAI has made in the past two decades, said newly installed (continued on page 4) This spring SCAI earned Accreditation with Commendation from the Accreditation Council for Continuing Medical Education (ACCME). This six-year reaccreditation status is only held by roughly 15 percent of CME providers nationwide. We re thrilled with the result, says SCAI Education Committee Chair Timothy Sanborn, M.D.,, who was instrumental in SCAI s accreditation review, a process that entailed submitting four years of comprehensive program information. SCAI has made many positive changes in response to today s much more heavily scrutinized CME environment. The changes include a move to outcomes-driven initiatives founded explicitly in scientific data. In addition to the longstanding ACCME accreditation criteria, which focus primarily on funding transparency, ACCME now asks CME providers to identify and document gaps in physician practice, translate those gaps into educational programming, and measure the results. And these requirements are for just four-year ACCME accreditation. (continued on page 2) Excela Health Rebuilds Cath Lab Using SCAI-Quality Improvement Toolkit SCAI-QIT Was Essential for Earning ACE Accreditation When the cardiac cath lab at Westmoreland Hospital in Greenburg, PA, earned Accreditation for Cardiovascular Excellence (ACE) certification in January, the achievement capped a year of hard work and selfexamination. SCAI s Quality Improvement Toolkit (SCAI QIT) played an essential role in that success, according to Howard P. Grill, M.D., the cath lab s medical director. We used the tools in SCAI-QIT as a blueprint to ask ourselves, What s best practice? What defines quality? What are the things we should be focusing on? he said. Until now, there really hasn t been one place where you could go to find best practices in terms of structuring a cath lab. SCAI-QIT fills that void. (continued on page 5)

2 2 SCAI Reaccredited with Commendation (cont d from pg 1) Accreditation with Commendation is a sixyear reaccreditation given only to CME providers that meet the accreditation requirements while also demonstrating active engagement with their environment in support of physician learning as part of a larger system driving quality improvement. SCAI has always been a leader, providing broad-based Timothy Sanborn, M.D., educational programs like the SCAI Scientific Sessions, explains Dr. Sanborn. Now we are taking a more indepth look at the learner need behind the education, measuring the impact of our educational choices, and expanding our reach into more collaborative, techfriendly, and quality-driven programs. For SCAI, it s a natural progression. A prime example of SCAI s compliance with ACCME expectations is the SCAI Quality Improvement Toolkit (SCAI-QIT), which provides tools to help interventional cardiologists and cath lab teams identify opportunities for improvement and begin implementing changes to positively impact patient outcomes. SCAI-QIT perfectly illustrates how SCAI is operating at a different level than it was just 5 years ago, says SCAI Education Committee Co-chair Robert Applegate, M.D.,. It also reflects the speed at which the CME environment is changing. It s a Robert Applegate, M.D., real feather in SCAI s cap that it was recognized for its foresight in what has been a challenging time for many other CME providers. Other positive changes made by SCAI in this ACCME reaccreditation cycle include shifting from resort-based meetings to new online educational programs and providing programs around need-based topics, such as transradial diagnostics and interventions and gender disparities in cardiovascular care. SCAI is now partnering with greater frequency, a trend ACCME encourages and includes as part of its Accreditation with Commendation criteria. Examples include SCAI s work with the patient advocacy group Mended Hearts to develop CathPack, which provides recovery information distributed by volunteers to heart patients and their families. We continue to evolve in new and exciting directions, says Dr. Applegate. I think that in six years, when SCAI is up for its next reaccreditation, we ll see that SCAI has moved further in the direction of metric-driven education and outcomes analysis. The goal is to provide physicians with learning opportunities that positively impact patient care. Receiving the ACCME s premier accreditation designation shows SCAI s commitment to engaging in that process at the highest level. n SCAI News & Highlights is published by The Society for Cardiovascular Angiography and Interventions 2400 N Street, NW, Suite 500, Washington, DC Phone ; Fax info@scai.org J. Jeffrey Marshall, M.D.,, President Theodore Bass, M.D.,, President-Elect Christopher J. White, M.D.,, Immediate Past President Charles Chambers, M.D.,, Vice President Carl L. Tommaso, M.D.,, Treasurer James Blankenship, M.D.,, Secretary Morton Kern, M.D.,, Editor-in-Chief Trustees H. Vernon Anderson, M.D., Robert Applegate, M.D., Ralph R. Brindis, M.D., MPH, Jeffrey Cavendish, M.D., Peter L. Duffy, M.D., Anthony Farah, M.D., Cindy Grines, M.D., James Hermiller, M.D, Thomas Jones, M.D., Upendra Kaul, M.D., Clifford Kavinsky, M.D., Ph.D., Daniel Levi, M.D., Ahmed Magdy, M.D., Srihari S. Naidu, M.D., John P. Reilly, M.D., Kenneth Rosenfield, M.D., Huay-Cheem Tan, MBBS, Trustees for Life Frank J. Hildner, M.D., William C. Sheldon, M.D., Staff Norm Linsky Executive Director Wayne Powell Senior Director for Advocacy & Guidelines Terie King, CPA Senior Director of Accounting & Operations Bea Reyes Senior Director of Education & Meetings Kathy Boyd David Communications Director touch three Design and Production Imaging Zone Printing Follow us: SCAINOW SCAINEWS SCAI_PREZ SCAI_WIN SECONDSCOUNTORG

3 3 SCAI Welcomes New Trustees SCAI is pleased to welcome the following Fellows to the Board of Trustees or the Executive Committee: H. Vernon Anderson, M.D., Houston, TX Robert Applegate, M.D., Winston-Salem, NC James Blankenship, M.D., Secretary, SCAI Danville, PA Ralph R. Brindis, M.D., MPH, San Francisco, CA Peter L. Duffy, M.D., Pinehurst, NC Cindy Grines, M.D., Detroit, MI Daniel Levi, M.D., Los Angeles, CA John P. Reilly, M.D., New Orleans, LA Kenneth Rosenfield, M.D., Boston, MA SCAI thanks the following Fellows whose terms as Trustees or Executive Committee members ended in May Their service to the Society is gratefully acknowledged. Alexandre Abizaid, M.D., Ph.D., São Paulo, Brazil Lee Benson, M.D., Toronto, Canada Tyrone Collins, M.D., New Orleans, LA Larry Dean, M.D., Immediate Past President, SCAI Seattle, WA Runlin Gao, M.D., Beijing, China James Goldstein, M.D., Royal Oak, MI Issam Moussa, M.D., Jacksonville, FL Kimberly A. Skelding, M.D., Danville, PA Zoltan Turi, M.D., Camden, NJ

4 4 SCAI PAC (cont d from pg 1) What s in a Name? With the kick-off of a PAC, nonprofit organizations like SCAI become subject to a host of IRS rules, including some that impact things as fundamental as their name. For SCAI this means some basic restructuring of activities, so that certain efforts are conducted from the original nonprofit arm of the Society and others migrate to a newly formed entity. To comply with IRS regulations, SCAI has formed The SCAI Foundation, which now houses all educational and quality initiatives, as technically separate from SCAI, where advocacy and marketing efforts, for example, reside. Immediate Past President Dr. Christopher J. White and newly installed President J. Jeffrey Marshall were in full agreement about the necessity of a PAC for strengthening SCAI's advocacy voice. Here Dr. White performed the ceremonial "ribbon cutting," during which President-Elect becomes President. SCAI President J. Jeffrey Marshall, M.D.,. With government expanding its role in practically every facet of health care, we need tools that will expand our access to policymakers. The PAC is currently the best way for physicians to stand up for our profession and our patients. Christopher J. White, M.D.,, who closed his term as SCAI president with the formation of the PAC, said it was a key achievement of his year at the helm of SCAI. No one is going to look out for us and our patients except us, Dr. White said. It s our job, and with the PAC we will be in a better position to do what must be done. SCAI has already begun to see results, added Dr. White. With the PAC less than a month old and a congressional committee deliberating on a bill that would mandate certification for cath lab staff, the committee s ranking member, Rep. Frank Pallone, Jr. (D-NJ), met with SCAI lobbyist Wayne Powell. While SCAI supports credentialing of cath lab staff, we are concerned about which certifications will be recognized and how legislation on this issue could impact qualified but uncertified staff. We needed a meeting to make those concerns heard, but prior to forming the PAC we were unable to access the Representative himself, explained Mr. Powell. The PAC opened Rep. Pallone s door, and got SCAI s concerns heard. It doesn t appear that the bill will move forward without changes said Mr. Powell. This What does this mean for members? There s absolutely no change from the member perspective, says PAC Chair Dr. Tommaso. What was one organization is now technically two, but SCAI s mission and commitment to helping members deliver optimal patient care is the same, or even stronger because now we have the PAC. Don t be concerned if you see announcements from The SCAI Foundation versus just SCAI, adds President Dr. J. Jeffrey Marshall. We are still your Society, working 24 hours a day, 7 days a week, on behalf of interventional cardiologists and their patients. is an example of how the PAC could work on behalf of SCAI members. With the formation of its PAC, SCAI joins a host of other professions, not just in medicine, that have established PACs to support their advocacy efforts. Among them, noted PAC Chair Carl Tommaso, M.D.,, are vascular surgery, interventional radiology and thoracic surgery, as well as insurance companies, attorneys, and pharmaceutical and device companies. One key to a PAC s success, said Dr. Tommaso, is the participation and leadership of politically engaged members. Current members of SCAI s PAC are Joseph D. Babb, M.D.,, Robert Bersin, M.D.,, James Choi, M.D.,, Peter Duffy, M.D.,, Tony Farah, M.D.,, Steve Gigliotti, M.D.,, and Thomas Tu, M.D.,. These members will help ensure that SCAI complies with all IRS and PAC rules, while also helping to set priorities and goals for SCAI s new PAC. To volunteer, ask questions, or offer your opinions about the PAC, ask any of the PAC Committee members or contact Wayne Powell at or wpowell@scai.org. n

5 5 SCAI-QIT Helps Excela Rebuild (cont d from pg 1) Westmoreland s cath lab was in urgent need of restructuring when Dr. Grill took the helm in early Reports had just surfaced alleging that two interventional cardiologists had implanted unnecessary stents in at least 141 patients treated at Westmoreland. The cardiologists resigned from the hospital medical staff, but the investigation prompted dozens of lawsuits and tarnished the hospital s reputation. Excela Health, Westmoreland Hospital s parent organization, responded by hiring several new interventional cardiologists and bringing Dr. Grill on board to lead a top-to-bottom overhaul of the cath lab and its continuous quality improvement (CQI) program. He and his team decided to seek ACE accreditation as a way of demonstrating that their cath lab quality would stand up to the toughest possible scrutiny. It s one thing for the hospital to say, We ve recruited new people. We ve fixed it. Dr. Grill said. It s another thing to say, We ve recruited new people. We ve put in new standards. And the premier cardiac certification organization has come into our lab and said, Yes, it s been improved, it s functioning at the highest levels and you can feel confident in that. ACE can help a struggling cath lab get back on track, but any hospital can benefit from external review, said Bonnie H. Weiner, M.D.,, Board chair and chief medical officer of ACE. An objective outside observer Dr. Weiner discussed role of ACE in quality improvement at the SCAI 2012 Town Hall meeting can deliver to the facility the message, You need to do better in these areas. It can be an effective way to engage the physicians and their quality teams in moving forward, she said. In Excela s case, they also wanted external validation that the changes they had put in place were the right ones. Team Effort Despite the seriousness of the allegations, and the hit Westmoreland Hospital took to its public image, Dr. Grill found that the cath lab had a strong foundation. Protocols and procedures needed to be standardized and formalized processes SCAI-QIT was designed to address but the staff was top-notch. From the standpoint of quality, the cath lab staff here is every bit as good and able as the people I ve worked with at other hospitals, Dr. Grill said. They ve had many years of experience. That experience paid off as, over time, more and more cath lab staffers joined in the project to reorganize the cath lab Howard P. Grill, M.D. and revamp quality. Today, the cath lab team is involved in nearly all facets of the new CQI program. Westmoreland s CQI Committee, for example, was once the domain of physicians alone. Now its monthly meetings are also attended by nurses, technologists, and hospital quality improvement experts. Nurses and technologists work side-by-side with physicians in monitoring both the quality and appropriateness of angiography and interventions. A closed committee meets every week to review three angiograms and three interventional cases, all pulled at random. The angiograms are evaluated for procedural quality and report accuracy. The interventional cases are judged against appropriate use criteria. To make sure nothing slips through the cracks, triggers have also been established that automatically prompt case review. Among these triggers are the following: Intervention on a lesion of less than 50 percent stenosis; Stenting of three vessels in one procedure; Use of four or more stents per case; A delivered x-ray dose to the patient of more than 5,000 mgy; and Use of a large amount of contrast media. There are also monthly CQI conferences. And each quarter when National Cardiovascular Data Registry (NCDR) benchmarking and appropriate use reports are released, the findings are shared with everyone at the CQI conference both the areas of excellence and the areas in need in improvement. By having these educational conferences and reviews, as recommended in the SCAI-QIT, we have created a greater degree of accountability and better communication about the policies and best practices across the board, Dr. Grill said. Everybody who is working in the cath lab is aware of where we re doing great and where we face challenges. Best Practices In addition to establishing a structure for education and oversight, Dr. Grill and his team set to work formalizing clinical best practices. For example, using SCAI-QIT as a guide, they beefed up Westmoreland s radiation safety

6 6 program. The cath lab instituted a series of radiation safety lectures by the health system s radiation officer, making attendance mandatory for cath lab nurses, technologists and medical staff, and offering continuing education credits to attendees. The lectures proved so popular staff from the interventional radiology department joined in. They also put together a cath lab radiation safety committee, consisting of Dr. Grill, the cath lab manager, and several nurses and technologists. The committee developed a new policy to track the average radiation dose delivered to the patient for both diagnostic and interventional procedures. Technologists now inform the interventionalist or angiographer when the delivered dose reaches 2500 mgy, 4000 mgy, and 5000 mgy. All cases with a radiation dose exceeding 5000 mgy are later reviewed. The cath lab team keeps a similarly close eye on the volume of contrast media used, and has instituted a procedure that ensures patients at high risk for contrast nephropathy get recommended follow-up. In the past, ordering post-procedure lab tests was left to the individual physician. Now, if a patient arrives at the cath lab with a creatinine of 1.5 mg/dl or greater, the nurse flags the discharge papers, and the patient automatically leaves with an order for follow-up blood work. It s a matter of bringing everybody together so we can all agree this is the way we re going to do the right thing, Dr. Grill said. It becomes part of the routine. The cath lab also recently introduced radial artery catheterization but not before instituting a formal program of education and training that included a requirement that the first five cases performed by each operator be proctored by a physician with expertise in radial artery access. In this process, even Dr. Grill became a trainee again. The program, which was launched in March, has experienced no radial artery complications to date. Reports and Forms SCAI-QIT also proved indispensable in helping Westmoreland standardize key cath lab reports. Before they began working toward accreditation, cath lab reports, while acceptable, varied in style and content from one physician to another. This often made it hard to find needed information, such as the fractional flow reserve. Reviewing SCAI-QIT convinced Dr. Grill of two things: 1. The cath lab reports needed be standardized; and 2. Each report needed to be a stand-alone document that could provide a clear picture about why the procedure was done, what specific therapeutic steps were taken, and what the results were. To achieve these goals, the cath lab team worked with software programmers to reconfigure the report format. Among other improvements, the results of fractional flow reserve and intravascular ultrasound are now prominently displayed. SCAI-QIT also guided the cath lab team in revamping pre-cath orders. They now include a clear area for documenting the indication for the procedure. Another new, simplified form called the CAD Presentation Sheet was developed to make sure that all data being submitted to the NCDR are accurate, without forcing abstractors to cull through each patient s medical record to find it. Before the patient is taken to the cath lab suite, the physician fills out the form listing such information as cardiac symptoms, anginal class, presence or absence of heart failure, heart failure class, and the results of stress testing, specifying whether the results signify low-, medium- or high-risk of future ischemic cardiac events. This form enables the operator to state the facts of each patient s case, and aligns the data with both NCDR and appropriate use criteria. Rebuilding the cath lab at Westmoreland required hard work and commitment from the entire cath lab team, Dr. Grill said. This project involved many, many people, and required an open-mindedness and willingness to embrace new ideas, which they very much did, Dr. Grill said. As you get started, it becomes like a bowling ball. It picks up momentum, more and more people get involved, and in the end you have a situation everybody can be proud of. For more information on SCAI-QIT and how you can sign up to be a Quality Champion, visit n The SCAI-Quality Improvement Toolkit was developed with founding support from and support from The Society gratefully acknowledges this support while taking sole responsibility for all content developed and disseminated through this effort.

7 7 Free SCAI-QIT Webinar on Diagnostic Cath AUC: Register Today Registration is open for Navigating the New Appropriate Use Criteria for Diagnostic Cardiac Catheterization, the latest installment in the free SCAI-QIT Webinar Series. The webinar will be held Wednesday, Aug. 15, from 1:00 to 2:00 p.m. Eastern Time, and will feature Steven R. Bailey, M.D.,, and Manesh R. Patel, M.D.,, lead authors of the ACCF/SCAI appropriate use criteria (AUC) for diagnostic catheterization. The webinar has been designed to answer questions and concerns clinicians may have about assessing cases in the context of the 166 clinical scenarios included in the AUC document. Webinar attendees will participate in a focused discussion of how the new AUC can be used to complement clinical judgment and how to incorporate this new document into quality improvement efforts. SCAI expects registration for this webinar to be very Steven R. Bailey, M.D., Manesh R. Patel, M.D., AUGUST 10-11, 2012 CHICAGO, ILLINOIS Free SCAI-QIT Webinars: Available for Download Anytime The complete library of SCAI-QIT Webinars is available to Quality Champions and others, providing detailed review of the SCAI-QIT tools and important documents essential to cath lab quality improvement. Download as many of the webinars as you like for free at SCAI-QIT: What the Cath Lab Standards Update Has to Offer for Quality Improvement Featuring Thomas M. Bashore, M.D.,, Charles E. Chambers, M.D.,, and Bonnie H Weiner, MD, MSEC, MBA, SCAI-QIT: Navigating the New Revascularization Appropriate Use Criteria Featuring Kalon Ho, M.D.,, and Gregory J. Dehmer, M.D., SCAI-QIT: Navigating the Revised Guidelines to PCI Featuring James Blankenship, M.D.,, and Sunil Rao, M.D., SCAI-QIT: Defining Quality in the Cath Lab and Facility and Environmental Controls Featuring Skip Anderson, M.D.,, and Charles E. Chambers, M.D., SCAI-QIT: Operator and Staff Requirements Featuring Steve Yakubov, M.D.,, and Lyndon Box, M.D., SCAI-QIT: Procedural Quality and Cath Lab Best Practices Featuring Kirk Garratt, M.D.,, Kalon Ho, M.D.,, and Srihari S. Naidu, M.D., THE CLI MEETING high, given the track record of the SCAI-QIT Webinar Series. Many Quality Champions attend the webinars with their cath teams and also download the archived programs, for future reference and sharing with colleagues. To register visit And don t miss this opportunity to enroll as a SCAI- QIT Quality Champion. Your cath lab team will have unparalleled access to SCAI-QIT s currently available tools and you ll be among the first to be notified each time a new tool is launched. Already a Quality Champion? We want to hear from you! Tell us how SCAI-QIT is helping you achieve your quality improvement goals, and give us feedback on the tools you ve tried. If your story will help other Quality Champions, we may feature it here, in SCAI News & Highlights. us at kbdavid@scai.org. n

8 Abstract Poster Sessions PERIPHERAL SESSIONS I Blew It! Sessions Main 8 Congenital Heart Disease CAS Advances in Platelet Inhibition STROKE INTERVENTIONS RCIS Review Course SCAI 2012 Las Vegas, NV May 9-12, 2012 Transradial Mini-Course Attendees Give SCAI 2012 Thumbs Up for High-Quality, Practice-Changing Education in a Collegial Environment The tracks-based curriculum helped attendees navigate and get the most out of their SCAI 2012 experience, said Program Codirectors Drs. James B. Hermiller and Kenneth Rosenfield. The SCAI 2012 Scientific Sessions, held May 9 12, in Las Vegas, NV, will go down in the Society s record books for many reasons, including attendance, expo activity and media coverage all surpassing every previous meeting. But the real news, said Program Co-directors James B. Hermiller, M.D.,, and Kenneth Rosenfield, M.D.,, is that the impact of SCAI 2012 will be felt in cardiovascular cath labs long after the meeting concluded. According to the evaluation data, SCAI 2012 attendees are going to be making changes in the ways they practice medicine in both procedural technique and approach to quality. Of professional attendee respondents, 98 percent said they intend to make changes, such as: Late Breaking C Greater emphasis on quality Increased use of appropriate use criteria (AUC) Expanded use of radial access as appropriate Modified management of CTOs Changed follow-up protocol for ASD device patients More use of FFR and IVUS Setting up structural heart disease programs In reviewing the SCAI 2012 evaluation data, there s a lot to be proud of, but the most important measure of a medical meeting today is that it impacts practice, said Dr. Hermiller. Both the anecdotal feedback and the data suggest SCAI 2012 accomplished this goal. Having this kind of impact was the driver behind a number of changes to the annual meeting program, said Dr. Rosenfield, who with Dr. Hermiller sought new ways to infuse individual sessions with dialogue about quality improvement. Our intention was to maintain SCAI s long tradition of excellence in education on new techniques, preventing and managing complications, and cutting-edge technology, while also addressing big issues that impact how our profession is perceived, he said. SCAI 2012 was an opportunity to bring the Interventional Cardiology community together and really talk about how we can make improvements. The timing for such discussion couldn t have been better. Just as SCAI 2012 kicked off, updated cath lab standards and new AUC for diagnostic catheterization were published. With these new practice-guiding documents fresh on everyone s minds, SCAI 2012 s new audience response system came in handy. Many session moderators polled attendees on how highlighted cases would be categorized in the AUC standards. And, in some sessions, post-poll dialogue focused on how to At left: You are leading the way forward, Dr. Elliott Fisher told interventional cardiologists during the SCAI 2012 Town Hall meeting. In making treatment recommendations, he urged, focus not on what is the matter with patients but on what matters to them. At right: SCAI 2012 assembled a record number of attendees for thoughtful, interactive education. At left: Steve Stanko, of the patient advocacy group Mended Hearts, was Dr. Jeff Marshall s 2012 Presidents Reception. At right: SCAI Trustee Dr. Jeffrey Cavendish discussed access Coronary Track session.

9 tenance of Certification E REVIEWS linical Trials Structural Heart Disease PERIPHERAL SESSIONS HIGH RISK PV Interventions Founders Lecture Mullins Lecture PCI TOP PRACTICE CHANGING STUDIES Watch for more SCAI 2012 Highlights in future newsletters! weight the AUC recommendations alongside clinical judgment and expertise. The meeting s top-rated session, based on mean ratings yielded from the evaluation data, was right on message. The SCAI-Quality Improvement Toolkit (SCAI-QIT) Workshop got attendees talking not just onsite but also on Twitter, with discussion in both venues highlighting the pros and cons of practicing in today s era of cost containment, public reporting, and high-profile court cases alleging overuse of procedures. As in years past, attendees praised the intimate feeling of SCAI s annual meetings, with comments such as these in response to the question: What did you like most about SCAI 2012? It was comprehensive, the mood was optimistic, large enough to be broad yet small enough to be interactive. The small feeling of the meeting, able to talk with my colleagues and the presenters, something not always possible at the large meetings. This sentiment was especially strong in the Congenital Heart Disease Track, which was directed by Daniel Levi, M.D.,, and Thomas Fagan, M.D.,. The Congenital Track received across-the-board enthusiastic feedback for its exceptional intimate nature ; highquality speakers ; and good discussions on complex cases. The implementation of topic tracks across the entire meeting was appreciated by attendees, many of whom commented positively on how this feature helped them focus on their interests while also popping in on other tracks. For example, many attendees chose to spend most of their time in the Coronary Track but made a point of visiting the Congenital Track for the hugely popular I Blew It sessions and the lectures by Julio Palmaz, M.D., SCAI 2012 by the Numbers The following percentages of responding attendees strongly agreed or agreed : The overall quality of SCAI 2012 information was excellent: Their medical knowledge was updated by attending SCAI 2012: They would recommend SCAI 2013 to colleagues: 95% 94% 91% or the Peripheral Track for sessions addressing deep vein thrombosis and pulmonary embolism. While the tracks helped attendees optimize their SCAI 2012 experience, many pointed out that the new On Demand program makes SCAI 2012 a meeting that keeps on giving. Debuting this year and achieving widespread approval, SCAI 2012 On Demand made it possible for attendees to attend one track in person but explore the other tracks as early as that evening, or upon return home. With SCAI 2012 on Demand, the meeting becomes one that will keep on giving for the whole year ahead, said Dr. Hermiller. Whether you attended the meeting or missed it, you can access multimedia re-creations with audio synchronized with slides, and then view them from PC, laptop, iphone or ipad. For more information or to download SCAI 2012 On Demand, visit And don t forget to mark your calendar for SCAI 2013, which will be held May 8 11 in Orlando, FL. To send your suggestions, breyes@scai.org. n special guest at the SCAI site complications during a Below: Nearly 200 poster presentations were presented at SCAI At left: The sold-out SCAI 2012 Expo bustled with activity. At right: Dr. Neil Wilson was among many pediatric/congenital heart disease specialists who participated in interactive discussions, such as during the highly rated I Blew It and Brain-Scratchers sessions.

10 10 Hot Topics SCAI 2012 s Hottest Topic: Appropriateness By Kartik Mani M.B.B.S. Dr. Mani If there was a single theme at the SCAI 2012 Scientific Sessions, it would have to be appropriateness. From the classrooms to the hallways, at the podium and during the Q&A, the Appropriate Use Criteria (AUC) dominated our discussion and debate. The professional societies, including SCAI, have created these guidelinesderived formulae for a number of reasons, not the least of which is to support us in our struggles with payors, legislators, and media. In theory, the AUC will help standardize care, so that whether in a university setting in the northeast or in a small community hospital in the southwest, patients can expect a similar standard of care because everyone is following the same rule-book. And, on its face, it makes sense to create clear standards for performing or withholding a diagnostic/ therapeutic approach in clinical practice. As the SCAI representative to one of the multi-society AUC review panels, I became convinced the AUC were the right approach. Sitting through nearly 18 hours of grueling debate with other cardiology specialists, internists and payors, I believed this consensus approach would yield clear directions for clinical practice that would help simplify clinical decision-making at all levels while simultaneously streamlining delivery and reimbursement of care and protecting the system from fraud and abuse. And so I was truly surprised by the disparity in my colleagues reactions to the AUC. In fact, I was stunned when an unscientific poll of SCAI 2012 attendees revealed, in almost all instances, equal proportions of strident protest, meek acceptance or complete befuddlement at the whole concept of AUC. One example played out during an interactive session moderated by SCAI 2012 Program Co-director Kenneth Rosenfield, M.D.,, and Samir Pancholy, M.D.,. The case featured a 54-year-old male construction worker who is a smoker with Rutherford 3 claudication and a completely occluded ipsilateral superficial femoral artery, on no medical therapy with no prior trial of exercise or smoking cessation. After erudite discussion, audience polling on a peripheral interventional approach revealed a vote split three ways: 33 The appropriate use criteria are in their awkward adolescence, said SCAI Trustee Dr. Ralph Brindis during his Hildner Lecture. He urged SCAI members to maintain their focus on quality-improvement initiatives. If we are not at the table, he said, we will be definitely be on the menu. SCAI 2012 attendees reported the meeting will impact the how they practice medicine. One example they cited: more attention to the AUC, a topic discussed and debated in many SCAI 2012 sessions. percent for Appropriate; 33 percent, Inappropriate; and 33 percent, Uncertain. A perfect lack of consensus on a seemingly straightforward case. How can this be? On the surface, invasive management and possible intervention appear Inappropriate. This is what the guidelines and the AUC would say because a peripheral intervention will not preserve the patient s limb and may or may not provide lasting relief to a smoker with diffuse atherosclerotic disease. But think about this case more pragmatically. In this patient s line of work in today s economy, PAD may predispose a construction worker to be less physically active and more likely to lose employment. As a young smoker, he is more likely to be lost to both follow-up and possible secondary prevention strategies. But in the interest of upholding the academic principle of exercise first, smoking cessation next and finally, if all else fails, interventional therapy, this man may find himself unemployed, more likely to be more sedentary and thus, more obese and at greater risk for cardiovascular mortality and morbidity. Or if, despite the AUC, we offer him the Inappropriate intervention and in sense reward his bad behavior, namely smoking will he be more likely to exercise because it won t hurt, more likely to quit smoking because he doesn t want to have another procedure, and more likely to adopt a healthier lifestyle? (continued on page 15)

11 11 Thank You Platinum Abbott Vascular Gold Boston Scientific Silver AstraZeneca Medtronic The Medicines Company Bronze Cook Medical Cordis, a Johnson & Johnson Company Daiichi Sankyo, Inc. and Lilly USA, LLC St. Jude Medical Terumo Interventional Systems SCAI also appreciates the educational grant support provided by Atrium Medical Corporation a MAQUET Getinge Group Company, Gilead Sciences and MEDRAD. SCAI thanks the following for their generous support of the SCAI 2012 Interventional Fellows Complex Coronary Complications (C3) Summit: Abbott Vascular Boston Scientific Cordis, a Johnson & Johnson Company St. Jude Medical The Medicines Company SCAI thanks Founding Supporter Daiichi Sankyo, Inc. and Lilly, USA LLC, and AstraZeneca for their support of the SCAI Quality Improvement Toolkit (SCAI QIT) Workshop. SCAI thanks the following for their support of the Emerging Leader Mentorship (ELM) Program Symposium: Abbott Vascular Abiomed, Inc. AGA Medical GE Healthcare Interventional Systems GE Healthcare Medical Diagnostics Guerbet

12 12 Early Career SCAI ELM Program Launches Leadership Careers in Interventional Cardiology: Call for Next Round of Applications to Begin Soon By Srihari S. Naidu, M.D., Launched in May 2011 after a highly competitive selection process, 10 early-career interventional cardiologists embarked on a two-year program as the inaugural class of SCAI ELM Fellows. Founded by SCAI and formally cosponsored by the American College of Cardiology and the Cardiovascular Research Foundation, the purpose of ELM (Emerging Leader Mentorship) is to become an important pipeline for interventional cardiology leadership. ELM takes highly qualified and motivated early-career interventionalists and tailors their education, mentorship and opportunities over two years of intense training toward autonomous, influential roles as educators, researchers and/or professional society leaders. Now at the half-way point of the first two-year program, we ve had a chance to reflect on what we ve accomplished. In many respects, everyone involved has been astonished by the outcomes at even this early juncture. When asked to comment on the program thus far, the benefits of the program were obvious to those involved. Here are just a few examples: I didn t know what to expect, but now I can tell you the program has far exceeded any expectations, said Jennifer Tremmel, M.D.,, ELM Fellow from Stanford. It was like being strapped to a rocket ship, said Doug Drachman, M.D.,, ELM Fellow from Massachusetts General Hospital. I m certain I would not be where I am today without the ELM Program, said Allen Jeremias, M.D.,, ELM Fellow from Stony Brook Medical Center in New York. Thank You SCAI thanks the following companies for their support of the Emerging Leader Mentorship (ELM) Program: Abbott Vascular Abiomed, Inc. AGA Medical GE Healthcare Interventional Systems GE Healthcare Medical Diagnostics Guerbet This is strong praise for a program that is only a year old and remains, programmatically, a work in progress. After being selected, each Fellow is paired with a National Mentor and also develops longitudinal relationships with those on the Program Committee, themselves chosen for their track record of mentorship. Over the two years, Fellows participate in six mandatory training sessions, timed with the annual meetings of SCAI, ACC, and TCT, as well as a series of satellite sessions covering various topics. Along the way, ELM Fellows are given both opportunities for national committee work within the different societies congruent with their developing leadership interests, and faculty speaking appointments at the national meetings. They are expected to work aggressively to form the network of collaborators and colleagues necessary for success at the national level. The program should not be measured solely on the success of the 10 selected Fellows, however. The surprise benefit of the program is that it speaks to young interventional cardiologists directly, making it obvious SCAI respects and values their work and potential for contributions at a high level. As Andrea Hickman, my staff partner for ELM, said, ELM makes it clear that SCAI is forward-thinking and open to new viewpoints and new blood. Virtually every committee we have is now populated at least in part by young, motivated early-career members who were brought in as part of the call for applications to the ELM Program. This outcome was no accident. After the selection process was complete, the Program Committee made personal calls to applicants who did not win a spot in the program, taking the time to understand their goals,

13 13 aspirations, and talents, and then finding ways to channel their energy into SCAI and partnering organizations. This is something we will continue to do in the future, as there is certainly enough work to go around. SCAI s leadership has made it clear that the ELM Program will remain a vital part of the Society for years to come. As SCAI President J. Jeffrey Marshall, M.D.,, said, We are proud of the ELM Program and what it has done for SCAI. A relatively simple concept, ELM has exceeded our expectations. We look forward to seeing what the 10 current Fellows accomplish over their careers, and also now look forward to a new batch of applicants. Applications for the ELM Class will open this summer via an online process available at Contact Andrea Hickman at for more information. n Dr. Naidu is director of both the cardiac catheterization laboratory and the Hypertrophic Cardiomyopathy Treatment Center at Winthrop University Hospital, and assistant professor of medicine at SUNY - Stony Brook School of Medicine in Mineola, NY. He is an SCAI Trustee and the chair of the Emerging Leader Mentorship (ELM) Program. Education Update Transradial Education: A Top Priority for SCAI in 2012 In response to highly rated and well-attended transradial programming in 2011, SCAI is continuing the Transradial Interventional Program (TRIP) and introducing the Radial Access Mentorship Program (RAMP). With a growing number of interventional cardiologists looking to SCAI for transradial education, we are proud to offer two unique opportunities designed for physicians with varying transradial experience, said TRIP Program Co-chair Samir Pancholy, M.D.,. TRIP: New and Improved in 2012 After SCAI hosted five successful programs focusing on fundamental transradial procedures, it has become clear physicians are ready to move on from the basics, added Dr. Pancholy. The first TRIP programs offered solid education on getting started in the transradial space, and now physicians are asking, What s next? he explained. So, SCAI is ready to take interventionalists to the next level by providing a newly designed Samir Pancholy, M.D., course that answers that question. SCAI s 2012 TRIP programs will be held Sept. 8 in Chicago and Dec. 15 in Houston. Each (continued on page 16) During the SCAI 2012 Transradial Mini-Symposium, Dr. Jennifer Tremmel walked a standing-room-only audience through a case she performed with her team at Stanford.

14 14 SCAI Announces Recipients of Interventional Cardiology Fellows-in-Training Grants In June SCAI released the results of this year s Interventional Cardiology Fellows-in-Training (FIT) Grants program. Following a highly competitive application process conducted this spring, SCAI awarded grants to 36 Accreditation Council for Graduate Medical Education (ACGME) accredited interventional cardiology training programs, listed below. These grants will support the training of fourthyear fellows enrolled in these medical centers during the academic year. Now in its fifth year, SCAI s FIT Grants program has distributed more than nine million dollars to over 80 training programs, making it possible for many interventional cardiology fellows to complete an additional year of training while also supporting fellows benefits, such as travel to educational meetings FIT Grant Recipients SCAI congratulates the following Interventional Cardiology Fellows-in-Training Grant recipients: Aurora Health Care Beth Israel Deaconess Medical Center Brown University Program, The Miriam Hospital Cedars-Sinai Medical Center Cleveland Clinic Columbia Presbyterian Medical Center Duke University Hospital Emory University Hospital Johns Hopkins University Program Massachusetts General Hospital New York Presbyterian Hospital (Cornell Campus) Program NorthShore University Health System Northwestern Memorial Hospital Ochsner Clinic Foundation Rush University Medical Center Scripps Clinic St. Vincent Hospital and Health Care Center Program Tufts-New England Medical Center University Hospitals Case Medical Center/Case Western Reserve University University of Alabama at Birmingham University of California (Irvine) Program University of California Davis University of Florida University of Iowa Hospitals & Clinics University of Kentucky at Lexington College of Medicine University of Missouri at Kansas City Program University of North Carolina Hospitals University of Pittsburgh Medical Center University of Texas at Houston Program University of Texas Health Sciences Center at San Antonio University of Vermont Program Vanderbilt University Medical Center Wake Forest University School of Medicine Program Washington Hospital Center Washington University School of Medicine Yale-New Haven Medical Center

15 15 The Society s FIT Grants program was established in 2007, when the Cordis Cardiac & Vascular Institute became the first of various industry partners to ask SCAI to facilitate their support of interventional cardiology fellows. The companies had budgeted funds to support interventional cardiology training spots approved by the ACGME but likely to go unfilled because the institutions lacked financial resources for them. In response, SCAI developed a process wherein institutional grant recipients would be chosen by a committee of interventional cardiology leaders who evaluated applications based on objective review against a number of criteria for excellence. It is an honor for SCAI to administer these grants in support of the education of tomorrow s interventional cardiologists, said SCAI FIT Grant Steering Committee Chair Joseph D. Babb, M.D.,. We know from the schools that have received grants in the past that they make a real difference, especially at a time when many feel their educational missions are threatened by dwindling resources. In fact, SCAI s FIT Grants program has become increasingly competitive as more training programs apply for support and funding diminishes in the face of a contracting economy and new challenges to healthcare industries. To that end, SCAI s already competitive process has grown more rigorous. This year, each grant application was scored by at least three physician reviewers, who included former or current program directors in interventional cardiology as well as structural, peripheral or vascular specialties, and by the members of the SCAI FIT Steering Committee. A statistician then analyzed the scores and delivered recommendations to the committee. Committee members included Robert Applegate, M.D.,, Tyrone Collins, M.D.,, Jonathan Tobis, M.D.,, and Barry Uretsky, M.D.,. On behalf of SCAI and the programs that have been able to train more interventional cardiology fellows through this program, we thank the Boston Scientific Foundation and Medtronic for making this program possible, said Dr. Babb. Applications for the SCAI FIT grants will be accepted this fall. Contact Sheila Agyeman at sagyeman@ scai.org for more information. n Thank You SCAI thanks the following companies, whose generous support made it possible for SCAI to award FIT grants for the academic year: Boston Scientific Foundation Medtronic Appropriateness (cont d from pg 10) In this case, would adherence to the AUC help this man or hurt him? Would society benefit by saving the cost of the intervention, or would it lose out on workforce productivity, purchasing power, and increased healthcare expenditure on his long-term illness? Or would disregarding the AUC for patients such as this one encourage abuse of the system by opportunists, including physicians, patients, and other groups who benefit from wide use of invasive procedures? This is one case, somewhat oversimplified to make a point. Despite what I personally might prefer for this patient, I still believe the AUC approach is sorely needed. If as a profession we do not develop AUC to shield ourselves from oncoming regulatory assault, the threat to our existence as interventionalists will become reality. Then who would suffer most? Ultimately, it would be our patients. Regardless of these cases, we will be needed; you still to treat STEMIs and CLI. Despite the best intentions of the AUC architects, in many situations the AUC cannot encompass the multiple layers and dimensions involved in individual cases. But they are the yardsticks on which you and I will be measured, and so we must work with them as best we can. When I arrived at SCAI 2012, I would have scored the concept of the AUC as Appropriate. After attending SCAI 2012, with its rigorous and eye-opening debates, I am not ready to label them Inappropriate but I am leaning toward a solid Uncertain. n Dr. Mani is chief of the Division of Internal Medicine at Mercy Medical Center in Roseburg, OR. He is a Board-certified interventional cardiologist and certified device specialist and an active SCAI member who participates in the Early-Career, escai, Structural Heart Disease, and Advocacy committees. SCAI thanks Hot Topics columnists for their work while noting the opinions and recommendations expressed are solely their own. Publication in Hot Topics does not constitute an endorsement by SCAI. To suggest a topic or volunteer to contribute a column, contact Kathy Boyd David at kbdavid@scai.org.

16 16 Transradial Education (cont d from pg 13) Sunil Rao, M.D., one-day program will offer attendees a refresher on basic access techniques, catheter selection and hemostasis while also highlighting advanced techniques, including traversing difficult anatomy, difficult interventional substrates, and non-coronary intervention. In addition to the didactic curriculum, the two TRIP programs will both include a nursing and technological symposium and simulator training. We re committed to providing physicians, nurses, and technicians the latest information in an accessible format, and TRIP is a great way to learn from the best of the best, said TRIP Program Co-chair Sunil Rao, M.D.,. TRIP features a worldclass faculty and provides access to the experts in a very hands-on setting. This program is a great choice for physicians who want to start their own transradial program as well as those who are looking to take the next step in their transradial education. For more information or to register for either TRIP program, visit RAMP: Transradial Preceptorship Brings Education to You New to SCAI s educational offerings is RAMP, a preceptorship program designed to complement the TRIP series. Aimed at medical centers and multispecialty practices, RAMP delivers on-site, in-person transradial training from physicians with extensive transradial experience. SCAI is really changing transradial education by offering the RAMP program, said RAMP Program Director Adhir Shroff, M.D.,. RAMP offers a completely unbiased and brand-neutral education that is ideal for hospital administrators and physicians who agree that radial training is important to their institutions. And it s a good way to start a program off on the right foot. Developed as a means of continuing access to Adhir Shroff, M.D., radial education and physician experts, RAMP picks up where the TRIP program leaves off, continued Dr. Shroff. TRIP provides an outstanding education to physicians interested in implementing radial, and then RAMP keeps the momentum going by offering on-site procedural training for a full hospital team. This type of training improves the likelihood that Thank You Since SCAI launched the Transradial Interventional Program (TRIP) in 2011, the following companies have generously supported the series: Platinum Medtronic Silver The Medicines Company Bronze Boston Scientific Cook Medical Cordis, a Johnson & Johnson Company Daiichi Sankyo Lilly, Inc. and Lilly, USA LLC Terumo Interventional Systems The Society gratefully acknowledges this support while taking sole responsibility for all content developed and disseminated through this effort. physicians will adopt the radial approach and maintain a radial practice. Structured to maximize physician interaction, RAMP provides one day of didactic curriculum focusing on the basics of starting a transradial program and then transitions to an extensive hands-on training session. These programs will provide a great opportunity for physicians to learn common technical aspects of the radial approach, particularly with regard to patient and lesion assessment and catheter selection, said Dr. Rao. Learning from an expert in your home institution will provide just the right setting to gain full exposure to the complications and recommended therapies for this approach. The RAMP program will be available in the second half of The RAMP program will be available in the second half of For more information about the RAMP program, contact SCAI Associate Director of Educational Planning and Market Research Georgina Lopez-Cruz at or via at glopezcruz@ scai.org. n

17 CME Calendar SCAI program 17 From SCAI And partners Program jointly sponsored with SCAI Program cosponsored by SCAI JULY 2012 Complex Interventional Cardiovascular Therapy (CICT) Date: July 27 28, 2012 Location: San Francisco, CA Directors: Issam Moussa, M.D.,, and Joseph DeGregorio, M.D., AUGUST 2012 Amputation Prevention Symposium Date: Aug , 2012 Location: Chicago, IL Director: Jihad Mustapha, M.D., For more info: SEPTEMBER 2012 Transradial Interventional Program (TRIP) Date: Sept. 8, 2012 Location: Chicago, IL Directors: Samir Pancholy, M.D,,, and Sunil Rao, M.D., For more info: AIM Radial Date: Sept , 2012 Location: Quebec City, Canada Director: Olivier Bertrand, M.D,, For more info: The Veins Chicago 2012 Date: Sept , 2012 Location: Chicago, IL Directors: Gregory Mishkel, M.D.,, and Raghu Kolluri, M.D. For more info: OCTOBER 2012 Duke Transradial Masters Course Date: Oct , 2012 Location: Durham, NC Director: Sunil Rao, M.D.,, and Mitchell Krucoff, M.D., For more info: transradial-master-course Heart Valve Summit Date: Oct , 2012 Location: Chicago, IL Directors: David Adams, M.D., Steven Bolling, M.D., Robert Bonow, M.D., and Howard Herrmann, M.D., For more info: Conferences/2012/October-2012/Heart-Valve.aspx DECEMBER 2012 SCAI 2012 Fall Fellows Course Date: Dec. 5 8, 2012 Location: Las Vegas, NV Directors: Ted Feldman, M.D.,, Zoltan Turi, M.D.,, and Ziyad M. Hijazi, M.D., MPH, For more info: Transradial Interventional Program (TRIP) Date: Dec. 15, 2012 Location: Houston, TX Directors: Samir Pancholy, M.D.,, and Sunil Rao, M.D., For more info: MAY 2013 SCAI 2013 Scientific Sessions Date: May 8 11, 2013 Location: Orlando, FL Co-chairs: Kenneth Rosenfield, M.D.,, Morton Kern, M.D.,, Thomas E. Fagan, M.D.,, and Matthew J. Gillespie, M.D., For more info:

18 18 Coding Q&A Coding for Renal PTA/Stenting and Dx Renal Angiography: Clear Documentation Essential renal PTA (percutaneous transluminal angioplasty) be reported in conjunction with Q:Can renal stent placement? Is preceding diagnostic angiography additionally reportable? is an important and timely question because renal PTA has landed in the A:This crosshairs for revaluation by the Centers for Medicare and Medicaid Centers (CMS) and the RVS Update Committee (RUC). SCAI s CPT and RUC representatives, Arthur Lee, M.D.,, and Clifford Kavinsky, M.D.,, are collaborating with other members of the cardiovascular CPT and RUC coalition to seek a reprieve in dealing with restructuring these codes until the 2014 CPT cycle. In the interim, it is imperative that SCAI members code these services correctly, particularly those for renal PTA. SCAI encourages all members to share this column with their billing staff and take steps to ensure their practices are properly reporting these services. The key point to remember is this: When the intended intervention is primary stenting, PTA performed to predilate or as the method for stent deployment is NEVER a separately coded service. However, PTA is additionally reportable with stent placement when the intention was to perform angioplasty as the primary intervention, AND the stent placement was performed only after failed or suboptimal results from the angioplasty. To bill both renal PTA and stent interventions of the same vessel, the patient record must clearly establish angioplasty as the intended intervention. Most experts agree orificial lesions (the most common lesions involving the renal arteries) should be treated by primary stenting; therefore, renal PTA would not be expected to be commonly reported in conjunction with renal stenting procedures. Renal PTA and stenting are still currently component coded, with catheterization, intervention, and supervision and interpretation all separately reportable. Renal Catheterization Renal catheterization should be reported using the applicable catheterization code(s), as follows: Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Image courtesy of Dr. J. Jeffery Marshall Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) Therapeutic Renal PTA The codes to report therapeutic* renal PTA are Transluminal balloon angioplasty, percutaneous; renal or visceral artery Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation *Codes and may NOT be used when the intended intervention was to stent.

19 19 Renal Stenting The codes to report renal stenting are Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel PTA and stent placement codes are assigned per vessel, not per dilation or by the number of stents deployed. Follow-up radiological studies to check the results of angioplasty or stent placement are not separately coded. CMS has instructed, It is appropriate for a provider to bill for both a diagnostic angiogram/venogram RS&I and an interventional therapeutic vascular RS&I when the decision to perform the interventional therapeutic vascular procedure is based on the results of the preceding diagnostic angiogram/ venogram. Providers may bill both codes utilizing an NCCI associated modifier. The coding guidelines for diagnostic angiography performed at the time of an interventional procedure require that No prior catheter-based angiography/venographic study is available and a full diagnostic study is performed and the decision to intervene is based on the diagnostic study OR If a prior study is available, the medical record must document: The patient s condition with respect to the clinical indication has changed since the prior study, OR There is inadequate visualization of the anatomy and/or pathology, OR There is a clinical change during the procedure that requires new evaluation outside the target area of intervention One important requirement is that modifier 59 must be appended to the diagnostic imaging code(s) when the above criterion is met. Diagnostic Renal Angiography Diagnostic renal angiography performed from a nonselective catheter position is considered inherent to abdominal angiography and not separately reportable. In contrast, renal angiography performed from a selective catheter position is reportable using one of the following applicable codes: Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral n Please note: SCAI is committed to making every reasonable effort to provide accurate information regarding the use of CPT, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. SCAI assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payors or Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors are copyright 2012 by the American Medical Association.

20 The Society for Cardiovascular Angiography and Interventions 2400 N Street, NW, Suite 604 Washington, DC Phone Fax Non-Profit Organization U.S. postage paid Suburban, MD Permit No Radial TRIP Artery Occlusion Prevention & Manag Peripheral TRI Transradial Interventional Program Series EMBOLIC RISK & RADIATION SCAI EXPOSURE WITH TRI Now with Advanced Content, Procedural Techniques & Best Practices! Guide Catheter Basics CO-CHAIRS: Samir B. Pancholy, MD, & Sunil V. Rao, MD, Chicago, IL Simulator Session September 8 December 15 Antithrombotic therapy with TRI The Society for Cardiovascular Angiography and Interventions Houston, TX Post Procedura Protocol REGISTER NOW!

21 OVERFLOW from pg. 7 e l s