Monday, August 2, 2010

CPT 74400,74410,74415,S8037 - MRCP - 74181, 74182, 74183

Injection Not Separately Reimbursable

Reimbursement for the following procedures includes the value of the injection procedure.  When billing for these radiological procedures, providers should not submit a separate charge for the injection procedure.

Procedure-4 Code    Description

74400    Urography (pyelography), intravenous, with or without KUB, with or without tomography
74410    Urography, infusion, drip technique and/or bolus technique;
74415        with nephrotomography
S8037 - Magnetic resonance cholangiopancreatography (mrcp)



74181 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material
74182 Magnetic resonance (e.g., proton) imaging, abdomen; with contrast material
74183 Magnetic resonance (e.g., proton) imaging, abdomen; ‘without contrast material’ followed by ‘with contrast material’ and further sequences

Magnetic Resonance Imaging

Refer to the Radiology:  Diagnostic section of this manual for information about the following services:

•    Magnetic resonance imaging (MRI)
•    Magnetic resonance angiography (MRA)
•    Magnetic resonance cholangiopancreatography (MRCP)

Description

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for imaging the biliary and pancreatic ducts using magnetic resonance imaging. These techniques do not require intravenous contrast material and use specialized MRI sequences (i.e., heavily T2- weighted) to make the fluid in the ducts appear bright while the surrounding organs and tissues are suppressed and appear dark. Additional technical factors include fast imaging to reduce motion artifact and sufficient resolution to detect small ductal structures and pathology. When imaging pediatric subjects, a very small field of view and high pixel matrix provide better spatial resolution for small structures. Modifications of the MRCP protocol to include secretin infusion and functional evaluation have also been explored.

MRCP has been proposed as a noninvasive alternative to more invasive imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), percutaneous cholangiography, or intravenous cholangiography (IVC). ERCP is an invasive  rocedure using a long specialized endoscope that can cannulate the biliary tree. This procedure is associated with a risk of complications such as pancreatitis, bleeding, bowel perforation, infection, and rarely death, and it requires anesthesia, which is also associated with potential complications.

Percutaneous transhepatic cholangiography (PTC) is also invasive and requires placement of a needle through the liver into an intrahepatic duct. ERCP and PTC obtain diagnostic images by direct ductal injection of radiographic contrast, while IVC uses radiographic contrast that is injected into the bloodstream and later excreted into the bile ducts. ERCP or PTC may also  be used to perform therapeutic interventions such as stent placement for obstruction, stone removal, or sphincterotomy. In addition, ERCP may not be technically successful in approximately 3% to 10% of cases, depending on operator skill and/or complex anatomy. Finally, MRCP is able to demonstrate the ducts beyond an obstructing lesion, whereas this may be difficult with ERCP or PTC.

Policy

Magnetic resonance cholangiopancreatography (MRCP) may be considered medically necessary for diagnostic evaluation of the pancreaticobiliary system for the following:

* In patients with suspected biliary and/or pancreatic ductal abnormalities, following incomplete or failed ERCP, or when ERCP cannot be safely performed (for example, a significant allergy to iodinated contrast material which would complicate performance of an ERCP)

* When ERCP is precluded by anatomic considerations, such as a biliary-enteric surgical anastomosis (for example, from previous choledochojejunostomy and partial gastrectomy with Billroth II anastomosis)

* To evaluate patients with biliary tract dilatation, biochemical evidence of biliary obstruction and/or unexplained RUQ pain, including detection of choledocholithiasis, benign stricture, mass lesion (benign or malignant), fistula and other
pathologic processes

* Status post cholecystectomy and high clinical suspicion for choledocholithiasis

* Following pancreatic ductal trauma, when ERCP is contraindicated, to assess ductal integrity and pseudocyst formation

* In recurrent acute pancreatitis of unknown etiology, to identify possible causes such as congenitally aberrant ductal anatomy (for example, Choledochal Cyst, Pancreas Divisum and Annular Pancreas)

* Primary Sclerosing Cholangitis


INDICATIONS FOR MRCP:

* For evaluation of suspected congenital anomaly of the pancreaticobiliary tract, e.g., aberrant ducts, choledochal cysts, pancreas divisum or related complications.

* For evaluation of chronic pancreatitis or the complications related to such (pseudocysts and bile duct strictures). Preoperative evaluation: Prior to surgery or other invasive procedure.
* Post operative evaluation: For evaluation of suspected biliary abnormalities after surgery or invasive procedure.

* For further evaluation of inconclusive abnormalities identified on other imaging (ultrasound, CT, or MRI).

* For evaluation of abnormality related to the biliary tree based on symptoms or laboratory findings and initial imaging has been performed.

Magnetic resonance Cholangiopancreatography (MRCP) – MRCP is a noninvasive method for depicting biliary and pancreatic ducts and assessing the level of obstruction. It is also used to evaluate congenital anomalies of these structures. In clinical practice MRCP is often combined with conventional MRI imaging of the liver and pancreas. MRCP does not require the use of any contrast materials. Unlike ERCP, it does not combine diagnosis with therapeutic intervention. MRCP is not cost effective if the patient will need ERCP mediated intervention after the MRCP. MRCP is preferred over ERCP when a noninvasive examination is needed or when there is a very small likelihood that the patient will need therapeutic intervention afforded by ERCP. Secretin-enhanced MR Cholangiopancreatography has been recently developed to improve the diagnostic quality of MRCP images.


MRI of the Abdomen

Providers can expedite a request by submitting a prior authorization request through e-referral and completing the appropriate questionnaire. If all questions are answered, e-referral will determine the status of the case based on the provider’s response.

If the case pends and BCN cannot authorize it, BCN will contact the provider for additional clinical information. Code*** Description

74181 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material
74182 Magnetic resonance (e.g., proton) imaging, abdomen; with contrast material
74183 Magnetic resonance (e.g., proton) imaging, abdomen; ‘without contrast material’ followed by ‘with contrast material’ and further sequences

1. Does the patient have:

2. An abdominal mass that has been characterized (that led to a definitive diagnosis) on CT/ultrasound*
* Yes
* No

3. An abdominal mass shown on CT or ultrasound of abdomen AND was not able to lead to a definitive diagnosis AND further imaging is recommended or required*
* Yes
* No

4. Limited CT scan, requiring MRI (i.e., unable to complete, contrast allergy, where only noncontrast study is able to be performed)*
* Yes
* No

5. Widely spread liver abnormality, without definitive diagnosis with CT/ultrasound* * Yes
* No

6. Abnormality of biliary or pancreatic ducts* (Consider magnetic resonance cholangiopancreatography (MRCP); CPT Code 74181***)
* Yes
* No

http://www.imaginghealthcare.com/wp-content/uploads/2016/01/IHS_CPT_Reference_Guide_V0116.pdf

MRI abdomen w/ & w/o contrast

MRA abdomen w/ or w/o contrast

*If exam includes history of gall stones, gall bladder disease, bile duct dilation, cholangitis, biliary tumor or pancreatitis include MRCP.
• Abdominal pain
• Any complaint related to liver, spleen, pancreas or kidneys
• Hypertension
• Renal artery stenosis 74183

74185 MRI abdomen w/ & w/o contrast w/ MRCP
• Common bile duct or gallbladder concerns
• Pancreatic duct 74183, 76377 MRI abdomen and pelvis w/ & w/o contrast
• Crohn’s disease
• Inflammatory bowel disease
• Ischemic bowel disease

74183 Abdomen w/ & w/o 72197 Pelvis w/& w/o MRI pelvis w/o contrast

• Coccyx fracture • Pelvic fracture
• Pubic arthralgia • Sacral fracture
• Sacroiliitis • Sports hernia
• Stress fracture (Pelvis)

72195 MRI pelvis and prostate gland w/ & w/o contrast • Prostate cancer screening, staging or follow up 72197

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