3D Imaging in Radiology

Gordon J. Harris, Ph.D.

Director, 3D Imaging Service and Radiology Computer Aided Diagnostics Laboratory,

Massachusetts General Hospital

Director, Tumor Imaging Metrics CoreDana Farber/Harvard Cancer Center

Associate Professor of Radiology,Harvard Medical School

Acknowledgements

• Dr. James Thrall, Chairman Radiology, MGH• Dr. R. Gil Gonzalez, Chief Neuroradiology, MGH• 3D Imaging Service Staff: Jennifer McGowan,

Peggy MacWilliams, Sally Pinho, Kate Weiss, Joan Beaudoin, Julie Della Monica, Jane Kelley, Fresnel Josaphat, Anthony Ranson, Shirley Thurston, Jonathan Lombardi, Trinity Urban, Dierdre Pierce, Joyce Miller, Bill Hanlon, Jon DeVries, Hiro Yoshida, Wenli Cai, Janne Nappi, Vadim Frenkel

3D Imaging Overview

• Goals of 3D Imaging Service• 3D Imaging and Clinical Benefits• 3D Imaging Service at MGH

– Clinical Exam Volume– Staff– Workflow

• 3D Billing and Reimbursement

Goals of 3D Clinical Service

• Integrate Computer Aided Diagnosis (visualization, quantitative analysis) into routine clinical workflow

• Bridge research and clinical applications to migrate new technologies into clinical practice

3D ImagingAxial images are ‘stacked’ into a three-

dimensional volume

Stacked Axial Slices 3D Volumesjn/MGH

Image Processing Techniques• Multi Planar Reconstruction (MPR / MPVR)

• Oblique and Curved Reformat

• MIP (Maximum Intensity Projection)

• Shaded Surface Display

• Volume Rendering

• Endoluminal Views (Virtual Colon, Bronch, Vessels)

• Functional Imaging

• CADx: Segmentation, Quantitation

2.5 mm

1.25 mm

MIP Rendering• Maximum Intensity Projection

• Displays the pixels of highest intensity along a ray

• Useful for vascular anatomy

sjn/MGH

Orthopaedics: Volume Rendering (VR)

Neurovascular Imaging: VR Curved

CT Bronchography: Endoluminal See-Through

Neurovascular CTA/MRA: VR MIP

Cardiac CTA: Normal 3˚CABG

Functional Analysis

- Image pixels derived froma function of changingsignal over time

•CT/MR Perfusion•fMRI

FunctionalCT Perfusion

CBV CBF MTT

Functional MR Perfusion

CBV CBF MTT

Functional MRI (fMRI)

Computer-Aided Segmentation

Total Volume = 1551.8cc’s

Semiautomated segmentationVirtual Hepatectomy

Left Lobe segment 316.91 cc’s

Virtual Hepatectomy

• Define surgical plane

• Sufficient volume for regeneration

Transplant segment

CADx: Automated Segmentation: VR MIP

CADx: Brain Tumor Volume

BRIGHT DARK TOTAL

126.92 22.696 149.62

Tumor Volume

CADx: Breast ImagingMR w/ registration/subtractionR2 Mammogram Image Check

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CT Angiography (CTA)

CT Urography (CTU)

CTA/CTU: non-invasive replacement-- Catheter Angiography PLUS IVP

Clinical Benefits of 3D Radiology

• More comprehensive and realistic views of patient

• Faster, more confident diagnoses and treatment planning decisions

• Reduced need for exploratory surgery

• Minimize surgical invasiveness and operating room time; reduced damage to healthy tissue

3D Imaging Service at MGH

• Clinical computer visualization for routine clinical use; 3D on request.

• Fast turnaround, full-time technologists

• Full integration with hospital PACS and information, billing systems

• Currently, over 2500 cases processed per month

3D Imaging Service Staff (13 FTEs)

• Director• Operations Manager• Administrator/Billing Coordinator• Technical Staff (2)• 3D Technologists (5)• Image Analysis Specialists (2)• 3D Ultrasound Technologist

3D Imaging Service Hardware and Software at MGH

5 GE Advantage Workstations5 Vital Images Vitrea WorkstationsTera Recon Aquarius Workstation and NetServer2 Voxar Workstations2 LINUX Computers with MedX/VolumePro for fMRIMirada Fusion7D Workstation for image registration3 GE LogiqWorks for 3D Reconstruction of USAGFA PACS Service Station, and RadWorks PACSMaterialize SimPlant/Master for Dental Implant PlanningMMS Preview LINUX ServerLINUX DICOM Server, 7 PCs, 2 Macs

MGH 3D IMAGING SERVICE:Daily Average Volume by Month

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20

40

60

80

100

120

140

160

FY' 99 2.3 4.7 7 6.9 8.7 9.2 10.9 10

FY' 00 16.9 18.4 16.3 17.4 17.6 17.3 22 24.4 24.1 25.4 26.6 30.3

FY'01 32.5 32.6 31.1 29.9 30 34.4 34.6 28.9 31.6 43.6 35.2 37.5

FY'02 39.1 40.2 40.7 45.5 47.6 46.7 51.2 55.3 49.5 55.5 52.2 62.4

FY'03 68.4 78.9 76.3 78.5 77.2 83.1 78.5 86.6 91.5 82.9 80.1 79.0

FY'04 82.7 84.3 75.6 88.7 90.7 90.3 89 102.5 99.3 92.5 102.4 110.6

FY'05 110.9 106.1 98 101.6 108.4 106.3 113.2 118.4 110.5 114 103 120.6

FY'06 122.6 120.4 114.7 122.8 116.8 115.6 110.8 126.9 129 126.2 125 138

October November December January February March April May June July August September

3D Imaging Service Clinical Workload at MGH

• 120 Exams per day processed– 30 per day MR Angiography (MRA)– 30 per day CT Angiography (CTA)– 30 per day other CT and MR exams– 30 per day Ultrasound

• Radiology Sub-Specialty breakdown– 50% Neuroradiology– 20% Vascular Radiololgy– 30% GI/GU, Chest, Breast, Bone, Pedi Radiology

• 20% of all MR,US Exams: ~16,000/80,000 per year• 10% of all CT Exams:

~ 12,000/120,000 per year

Original

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AGFA/PACS AGFA/PACS

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AMICAS WEB ServerAMICAS WEB Server

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PACS GatewayPACS Gateway

CT/MR scannerCT/MR scanner

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3D

Referring PhysicianReferring Physician’’s Desktops DesktopPC WEB BrowserPC WEB Browser

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AGFA/PACS AGFA/PACS

Radiologist View StationRadiologist View Station

AMICAS WEB ServerAMICAS WEB Server

3D

3D

AGFA/PACSAGFA/PACS

Radiologist View StationRadiologist View Station

AMICAS WEB ServerAMICAS WEB Server

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PACS GatewayPACS Gateway

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3D Workstation3D Workstation

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CombineCombineClinical Need Clinical Need

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BillingBillingCodesCodes

PACSPACSRoutingRouting

ScanScanProtocolsProtocols

3D3DProtocolsProtocols

ReferralReferralProtocolsProtocols

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Clinical Clinical NeedNeed

EvaluateEvaluateClinical Clinical ProductsProducts

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BillingBilling ComplianceComplianceClinicalClinicalWorkflowWorkflow

Imaging Protocols• Part of departmental scan protocols

• Billable Service

• CPT # 76377(6) for 3D reconstruction– Billed in association with Primary CT/MR/US code

• Requirements for Reimbursement:– Part of Departmental Protocol, Physician Notification– By specific request from physician– Positive finding by radiologist, requiring further views– Processing on FDA approved software

Billing and Reimbursement: 3D Add-on Code

• TC component -- if billed by Hospital:– Billed under HOPPS, APC 282– Reimbursed by Medicare at $95 (Nat’l Avg, 2007)

• TC component -- if billed by non-hospital:– Billed under MPFS (RVU-based)– Reimbursed by Medicare at ~$113 (Nat’l Avg, 2007)– Used if non-hospital imaging center, or 3D done by P.O.– Split or Global billing

• Prof. (-26) reimbursement ~$41

Billing and Reimbursement: 3D Add-on Code -- How to bill:

• Billed prior to 2001 with CPT # 76375• New CPT codes in 2001 for CTA• CTA and MRA now include post-processing

– 3D processing no longer separate charge for CTA/MRA

• PROBLEM: CTA was reimbursed same as CT– No additional reimbursement for added time, equipment

• We have achieved changes from Medicare– new APC in 2003 for CTA (need to improve charges)– Increased 2003 RVU TC reimbursement

Billing and Reimbursement: CT and MR Angiography (CTA/MRA)

Billing and Reimbursement: CTA Problems Continue!!

• Even with CMS changes in CTA, problems remain• APC Reimbursement set relative to claims data• Only 40% of hospitals charge more for CTA than

CT!! (Source: 2001, 2002 CMS claims data)• Most hospitals charge less for CTA than CT!!

- CMS example: Hospital Y charged ~4X for CT ($1,392) vs. CTA ($377)

• Impact: Reimbursement for CTA less than CT

• Prior to 2001, CTA was equal to CT PLUS 3D!• 2001 reimbursement was $114 higher for CTA• Hospitals must set charges accordingly

– Review Chargemaster and revise CTA charges relative to CT

• Charges for CTA should reflect sum of charges for CT (w/&w/out) plus charges for 3D (76375)

• Example: If CT charge is $1200, and if 3D charge is $400, CTA charge should be $1600

Billing and Reimbursement: CTA Charge Recommendations

Impact of New Technologies on Radiology

3D Visualization enables faster, more confident diagnoses and treatment decisions

Quantitative analysis and CADx can provide more accurate, reliable treatment planning, staging, and assessment

Improved patient care, increased clinical confidence, reduced time, cost, and invasiveness

Vision for the Future of 3D and CADx Services

Scale Up Services to Support Needs of Many Hospitals and Imaging Centers

Most Facilities Lack Resources and Expertise to Implement In-House Solution

Off-Hours Coverage Difficult

Use Advances in Networking and Communications to Centralize Services

Expand CADx and 3D Services

Advanced Core Lab

Thank you!!!Any Questions?