New policy effective August 30, 2024
Wisconsin Physicians Service (WPS) has joined the growing list of Medicare Administrative Contractors (MACs) who were successfully petitioned to expand the scope of ICD-10 codes qualifying for medical necessity for CT Perfusion studies.
MSN Healthcare Solutions has been involved in a multi-year team effort petitioning MACs to broaden medical necessity criteria for coverage of CPT Code 0042T, after many of them denied claims when patients presented with stroke symptoms but were found to be negative for stroke on imaging.
Renée Engle, RCC, RCCIR, MSN-ARC, FRBMA, MSN Sr. Vice President of Client Services, explained, “There is a narrow window of time for the effective treatment of stroke patients so prompt actions are critical. The problem arose if the patient had a negative study even if stroke symptoms were evident. This meant if the CT showed the patient didn’t have a stroke, the claim was denied as not medically necessary even if treatment decisions were made based on the results of the study, whether positive or negative.”
She continued, “We had the support of key physicians among our client groups to provide the clinical argument and scientific evidence to argue for payment of CT Perfusion studies based on the analysis of stroke symptoms even when negative findings occurred. We worked in conjunction with the American College of Radiology (ACR) and participated in the research, ongoing communications and persistent follow-up—and the results were successful.”
- States in WPS jurisdiction: Iowa, Kansas, Missouri, Nebraska, Indiana, Michigan
The following ICD-10 codes were published in the Billing Guidelines
Medical necessity requirements for CT Perfusion studies were also expanded for the Palmetto GBA and Noridian local coverage determinations as part of this effort.
