Why does a clinical history of “lightheadedness” for a head CT lead to a harsh email from your coding and billing department, while “dizziness” is smooth sailing? Who decides what an appropriate history is for a radiological exam? For Medicare billing, most of those decisions rest with the Medicare Administrative Contractors (MACs). Medicare is a $683 billion enterprise. Therefore, due to Medicare’s sheer size, CMS is unable to process all the nationwide claims — so it divides the country up into several “jurisdictions.” It then puts up for bid the claims processing contracts for each jurisdiction. Private insurance companies then bid for each contract, which lasts for up to seven years. One of the conditions of the contract is that each MAC needs to convene a group of physicians from multiple specialties and seek their advice in deciding which symptoms, signs, and diseases are appropriate for particular medical exams or procedures. These groups are the Contractor Advisory Committees (CACs). But, how would these CACs function on a national level?
In the first cross-country CAC, the topic of vertebroplasty and kyphoplasty was discussed. These spinal procedures involve the injection of bone cement into fractured vertebrae. After the MACs and CAC members met in a large national meeting at the beginning of 2019, several months passed before the local coverage determination (LCD) policies were written up — and it was a disaster. Payment for subacute fractures, which have always been covered and which the medical literature strongly supports, was suddenly stopped. It took several more months and numerous phone calls before these were put back on the payment list.
Fortunately, CAC members are still able to voice our concerns with the medical directors of each MAC, and that is how we need to exert our influence.
When your ACR CAC members learned that facet joint injections were to be discussed, we all held our breath. How would things turn out this time? The MACs and CAC members met virtually in May 2020, and the literature on the efficacy of these injections for chronic facet pain was discussed. After several hours of heated debate, radiology CAC members were unclear on what the new policy would look like. We only found out in March, and the result was significantly better than the initial vertebroplasty result. The facet joint LCD was what we expected. However, these meetings have revealed upcoming challenges with the new LCD policy development process. The input of radiology CAC members has become diluted with these large national meetings and, more recently, even been shut out completely. The topics of discussion have focused on spinal injections, which form a relatively small portion of most radiology practices. What happens if the MACs turn their attention to imaging protocols?
Fortunately, CAC members are still able to voice our concerns with the medical directors of each MAC, and that is how we need to exert our influence. It has never been more important to act locally, and we need to recruit engaged radiology CAC members for each state. If you are a CAC member but have not yet participated in an ACR CAC Network meeting, reach out to Alicia Blakey, ACR senior economic policy analyst, at firstname.lastname@example.org. We can help you get in touch with your ACR state chapter and tell you more about the CAC Network’s activities. The ACR CAC Network has become more critical now than ever.