Sometimes it just takes dogged determination and persistence to get things done. Since the end of 2022, MSN Healthcare Solutions has worked to change a Medicare Administrative Contractor (MAC) policy that will positively impact radiology practices. The MSN Insider recently chatted with Renee Engle, RCC, RCCIR, MSN-ARC, FRBMA, MSN Sr. Vice President of Client Services, about what it took to influence that change.
Insider: What was the problem with the policy?
Ms. Engle: Patients in the Palmetto GBA Medicare jurisdiction would present with stroke symptoms and physicians appropriately ordered a CT Cerebral Perfusion Analysis (0042T) to determine if the patient was experiencing a stroke. 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.
Insider: What did it take to get changes made?
Ms. Engle: Each Medicare jurisdiction establishes policies through their Local Coverage Determinations (LCDs) and MSN began the slow process of influencing change by petitioning each Medicare MAC to allow the inclusion of stroke symptoms as an indication of medical necessity. 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. It took research, ongoing communications and persistent follow-up but the Palmetto GBA modification was highly successful.
Insider: What are the changes and when is the revised policy effective?
Ms. Engle: MSN recommended the inclusion of an additional 25 signs and symptoms and all were published in the Billing Guidelines for the Palmetto GBA LCD, effective June 2, 2024.
While we hoped our recommendations would be accepted, we were delighted that none were rejected. We know this will help those practices who previously saw their procedures denied for medical necessity. This impacts the states of Alabama, Georgia, Tennessee, North Carolina, South Carolina, Virginia, and West Virginia.
Insider: What’s next?
Ms. Engle: Earlier in our efforts, Noridian Healthcare agreed to include sudden visual loss and slurred speech to their list of covered indications. We will continue to work with the various MACs regarding CT Perfusion studies and are optimistic as more signs and symptoms are approved as indications for medical necessity. I would like to emphasize this was truly a team effort and I am fortunate to work with a group of committed and passionate professionals who proved persistence, backed by expertise, can produce results.
Renee Engle
RCC, RCCIR, MSN-ARC, FRBMA
Sr. Vice President of Client Services
Renee represents MSN in the industry by serving on numerous committees, including the American College of Radiology (ACR) CPT and Nomenclature Committee, the Carrier Advisor Committee (CAC) and Payor Relations Network. She is also a member of the Radiology Business Management Association (RBMA) Payor Relations Committee and Federal Affairs Committee and is President of the Radiology Coding Certification Board (RCCB).
