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
0
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
Original
AGFA/PACS AGFA/PACS
Radiologist View StationRadiologist View Station
AMICAS WEB ServerAMICAS WEB Server
Original Scan
PACS GatewayPACS Gateway
CT/MR scannerCT/MR scanner
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Referring PhysicianReferring Physician’’s Desktops DesktopPC WEB BrowserPC WEB Browser
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Referring PhysicianReferring Physician’’s Desktops DesktopPC WEB BrowserPC WEB Browser
3D
Referring PhysicianReferring Physician’’s Desktops DesktopPC WEB BrowserPC WEB Browser
Original
Original
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
CT/MR scannerCT/MR scanner
Original Scan
PACS GatewayPACS Gateway
3D
3D Workstation3D Workstation
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CombineCombineClinical Need Clinical Need
withwithProductsProducts
BillingBillingCodesCodes
PACSPACSRoutingRouting
ScanScanProtocolsProtocols
3D3DProtocolsProtocols
ReferralReferralProtocolsProtocols
Implement
OR
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Clinical Clinical NeedNeed
EvaluateEvaluateClinical Clinical ProductsProducts
NewNewProductProduct
EvaluateEvaluateClinical Clinical
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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?