Approximately two years ago, MSN Healthcare Solutions responded to client concerns about Medicare Administrative Contractors (MACs) denying CT Cerebral Perfusion studies (CPT 0042T). These MACs covered only a few diagnosis codes for patients who were found positive for stroke and denied those with negative findings even if the CT was appropriate to validate patient status and determine treatment options. Practices with stroke centers were obviously heavily impacted.
MSN began contacting the various MACs and petitioned them to also include stroke symptoms when determining medical necessity. Renee 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 presented with stroke symptoms but subsequently had a negative CT perfusion study. 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, “The MSN team working to obtain approval had the support of key physicians among our client groups. These physicians provided 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 also worked in conjunction with the American College of Radiology (ACR) and are excited the results were successful.”
The process to petition the MACs for approval was specific and sometimes tedious. The work group hoped that once the first MAC approved an expanded list of diagnosis codes, others would follow more easily. That turned out to be a viable approach and 2024 results were gratifying. “It was definitely easier once we understood the process and required documentation,” Ms. Engle noted. “And fortunately our staff is diligent about monitoring regulatory changes so we didn’t have to spend an inordinate amount of time on the project once we submitted our baseline information. In several instances the effective date of the new policy was set retrospectively.”
Results and accepted diagnosis codes for CT Perfusion (by MAC):
Palmetto GBA revision effective June 2, 2024
Noridian Healthcare Solutions (Noridian) effective August 15, 2024
Wisconsin Physicians Service (WPS) effective August 30, 2024
National Government Services (NGS) effective September 15, 2024
