Tuesday, August 10, 2010

CPT code 70553, 70551, 70552 - MRI Brain procedure

Procedure code and Descripiton

70053 - Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences - average fee payment  - $390 - $400

70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material

70552 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); with contrast material(s


Coverage Indications, Limitations, and/or Medical Necessity


This policy addresses standard CT and MR imaging. Magnetic Resonance Angiography (MRA) is not addressed in this policy.

Computerized Tomography (CT)

Computerized tomography (CT scanning) uses the attenuation of an x-ray beam by an object in its path to create cross-sectional images. As x-rays pass through planes of the body, the photons are detected and recorded as they exit from different angles. Computers process the signals to produce a cross-sectional view of the body. The signal data may be subjected to a variety of post-acquisitional processing algorithms to obtain a multiplanar view of the anatomy.

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) is a non-invasive diagnostic scanning technique that employs a powerful and highly uniform static magnetic field, rather than ionizing radiation, to produce images. Fluctuations in the strength of the magnetic field alter the motion and relaxation times of hydrogen molecules, which are related to the density of molecules and reflect the physicochemical properties of the tissues. Reconstructed images can be displayed in multiple planes to facilitate analysis. See national non-coverage in CMS section above.

Coverage is limited to those CT and MRI machines that have received pre-market approval by the FDA. Such units must be operated within the parameters specified by the approval.

Medicare coverage for CT scans is allowed provided the service is medically reasonable and necessary.

Inconclusive findings on a CT scan may warrant a MRI study and, conversely, findings of a MRI study may be further clarified (under certain circumstances) with a subsequent CT scan. The information provided by the two modalities may be complementary.

Cancer Staging. Clinicians commonly use CT and MRI of the brain when metastatic involvement is suspected.

Non-covered indications: esophagus, oropharynx, and prostate, and non-melanoma skin cancer in the absence of symptoms of brain involvement. “Certain tumors almost never metastasize to the brain parenchyma. These include carcinomas of the esophagus, oropharynx, and prostate, and non-melanoma skin cancers.” (DeVita, Chapter 52.1) Accordingly, the related diagnoses found in the following diagnosis code list do not justify brain scans for “staging” purposes unless a patient has signs or symptoms suggesting brain involvement. Covered: In contrast, for those malignancies that commonly metastasize to the brain, staging in the absence of neurological findings may be appropriate.

Payment will be allowed for reasonable and necessary scans of different areas of the body that are performed on the same day.

For Symptoms -  Tumor/Mass/Cancer Pituitary lesion Cranial nerve lesions Acoustic neuroma HIV/AIDS Syringomyelia (Syrinx) Infection Visual change MS (Multiple Sclerosis) Metastases Neurofibromatosis Vascular lesions (AVM) Hearing loss/IAC mass Bell’s palsy (facial weakness)

Trauma Pseudotumor Grave’s disease Tumor/Mass/Cancer/Mets Exopthalmos/Proptosis Vascular lesions (Hemangioma)

Exam Indicator - MRI Brain WWO · Reasons: mass, tumor, cancer, multiple sclerosis, seizures

MRI Pituitary WWO · Reasons: abnormal prolactin blood level (female), hypogonadism (male)


Coverage Indications, Limitations, and/or Medical Necessity

    Magnetic Resonance Imaging (MRI) is used to diagnose a variety of central nervous system disorders. Unlike computed tomography (CT) scanning, MRI does not make use of ionizing radiation or require iodinated contrast material to distinguish normal from pathologic tissue. Rather, the difference in the number of protons contained within hydrogen-rich molecules in the body (water, proteins, lipids, and other macromolecules) determines recorded image qualities and makes possible the distinction of white from gray matter, tumor from normal tissue, and flowing blood within vascular structures.

    MRI provides superior tissue contrast when compared to CT, is able to image in multiple planes, is not affected by bone artifact, provides vascular imaging capability, and makes use of safer contrast media (gadolinium chelate agents). Its major disadvantage over CT is the longer scanning time required for study, making it less useful for emergency evaluations of acute bleeding or for unstable patients. Because a powerful magnetic field is required to obtain an MRI, patients with ferromagnetic materials in place may not be able to undergo MRI study. These include patients with cardiac pacemakers, implanted neurostimulators, cochlear implants, metal in the eye and older ferromagnetic intracranial aneurysm clips. All of these may be potentially displaced when exposed to the powerful magnetic fields used in MRI.

    Magnetic Resonance Imaging of the Brain will be considered medically reasonable and necessary when used to aid in the diagnosis of lesions of the brain and to assist in therapeutic decision making in the following conditions:

    · For detecting or evaluating extra-axial tumors, A-V malformations, cavernous hemangiomas, small intracranial aneurysms, cranial nerve lesions, demyelination disorders including multiple sclerosis, lesions near dense bone, acoustic neuromas, pituitary lesions, and brain radiation injuries;

    · For development abnormalities of the brain including neuroectodermal dysplasia;

    · For subacute central nervous system hemorrhage or hematoma;

    · For acute cerebrovascular accidents;

    · For complex partial seizures, seizures refractory to therapy, temporal lobe epilepsy, or other atypical seizure disorders;

    · MRI is usually not the procedure of choice in patients who have acute head trauma, acute intracranial bleeding, or investigation of skull fracture or other bone abnormality, or as follow-up for hydrocephalus. However, a MRI may be necessary in patients whose presentation indicates a focal problem or who have had a recent significant change in symptomatology;

    · For brain infections;

    · Where soft tissue contrast is necessary;

    · When bone artifacts limit CT, or coronal, coronosagittal or parasagittal images are desired; [and]

    · For procedures in which iodinated contrast material are contraindicated.

    Contraindications:

    The MRI is not covered when the following patient-specific contraindications are present:

    • MRI is not covered for patients with cardiac pacemakers or with metallic clips on vascular aneurysms unless the Medicare beneficiary meets the provisions of the following exceptions:

    Effective for claims with dates of service on or after July 7, 2011, the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment, or effective for claims with dates of service on or after February 24, 2011, CMS believes that the evidence is promising although not yet convincing that MRI will improve patient health outcomes if certain safeguards are in place to ensure that the exposure of the device to an MRI environment adversely affects neither the interpretation of the MRI result nor the proper functioning of the implanted device itself. We believe that specific precautions (as listed below) could maximize benefits of MRI exposure for beneficiaries enrolled in clinical trials designed to assess the utility and safety of MRI exposure. Therefore, CMS determines that MRI will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) (consistent with section 1142 of the Act) through the Coverage with Study Participation (CSP) form of Coverage with Evidence Development (CED) if the study meets the criteria in each of the three paragraphs in CMS Pub 100-03, CMS National Coverage Determination Manual, Chapter 1, Section 220.2.C.1.

    • MRI during a viable pregnancy is also contraindicated at this time.

    • The danger inherent in bringing ferromagnetic materials within range of MRI units generally constrains the use of MRI on acutely ill patients requiring life support systems and monitoring devices that employ ferromagnetic materials.

    • In addition, the long imaging time and the enclosed position of the patient may result in claustrophobia, making patients who have a history of claustrophobia unsuitable candidates for MRI procedures.

    Nationally Non-Covered Indications:

    CMS has determined that MRI of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications, are not considered reasonable and necessary indications within the meaning of section 1862(a)(1)(A) of the Act, and are therefore non-covered.

    When Magnetic Resonance Imaging is used for an investigational purpose, an acceptable advance notice of denial of payment must be given to the patient when the provider does not want to accept financial responsibility for the service.

Extra-axial tumors, A-V malformations, cavernous hemangiomas, small intracranial aneurysms, cranial nerve lesions, demyelination disorders including multiple sclerosis, lesions near dense bone, acoustic neuromas, pituitary lesions, and brain radiation injuries;

Developmental abnormalities of the brain including neuroectodermal dysplasia;

Subacute central nervous system hemorrhage or hematoma;

Acute cerebrovascular accidents;

Complex partial seizures, seizures refractory to therapy, temporal lobe epilepsy, or other atypical seizure disorders;

Patients whose presentation indicates a focal problem or who have had a recent significant change in neurologic symptomology;

Brain infections;

Conditions where soft tissue contrast is necessary;

When bone artifacts limit CT

Coronal, coronosagittal or parasagittal images are desired; and/or

Procedures in which iodinated contrast material are contraindicated.

Limitations

MRI is usually not the procedure of choice in patients who have acute head trauma, acute intracranial bleeding, for investigation of skull fracture or other bone abnormality, or as follow-up for hydrocephalus.

For 2007 CPT codes 70554 and 70555 have been added. Coverage for these CPT codes is not covered in this LCD.

Certain uses of MRI are considered investigational, and are therefore, not covered by Medicare. These include:

spectroscopy; 
cortical bone and calcifications imaging;
procedures involving spatial resolution of bone or calcifications.

Three dimension reconstruction of MRI of the Brain (CPT code 76376 or 76377) is expected to be utilized rarely. CPT 76376 or 76377 are not an appropriate part of every MRI examination.

For patients with cardiac pacemakers or metallic clips on vascular aneurysms, please refer to the National Coverage Determination (NCD) for Magnetic Resonance Imaging (220.2) for special provisions of coverage.


CPT/HCPCS Codes

70551 Mri brain stem w/o dye
70552 Mri brain stem w/dye
70553 Mri brain stem w/o & w/dye


Billing Coding Information 

MRI procedure codes (70549, 70553, 70559, 71552, 72197, 73220, 73223, 73720, 73723, and 74183), should be reported only once per day. Per national Medicare regulations, these Procedure codes are subject to the Correct Coding Initiative (CCI) edits.

A diagnostic technique has been developed under which an MRI of the brain or spine is first performed without contrast material, then another MRI is performed with a standard (0.1mmol/kg) dose of contrast material and, based on the need to achieve a better image, a third MRI is performed with an additional double dosage (0.2mmol/kg) of contrast material. When the high-dose contrast technique is utilized, A/B MACs (B):

• Do not pay separately for the contrast material used in the second MRI procedure;

• Pay for the contrast material given for the third MRI procedure through supply code Q9952, the replacement code for A4643, when billed with Current Procedural Terminology (Procedure ) codes 70553, 72156, 72157, and 72158;

• Do not pay for the third MRI procedure. For example, in the case of an MRI of the brain, if Procedure code 70553 (without contrast material, followed by with contrast material(s) and further sequences) is billed, make no payment for Procedure code 70551 (without contrast material(s)), the additional procedure given for the purpose of administering the double dosage, furnished during the same session. Medicare does not pay for the third procedure (as distinguished from the contrast material) because the Procedure code definition of code 70553 includes all further sequences; and



CPT 70551 CPT 70552 CPT 70553 Order when evaluating for: 

** Acqueductal Stenosis
** Altered Mental Status
** Confusion
** Dementia / Alzheimer’s
** Memory Loss
** Psychiatric Disorder
** Trauma
** Only done when an MRI of the Brain was performed WITHOUT IV Contrast previously
** Headaches
** Abscess
** Aneurysm**
** AVM / Vascular Lesions
** Dizziness
** Encephalitis
** IAC (Hearing Loss, Vertigo)
** Indeterminate intracranial lesion
** Meningitis
** Metastasis/Neoplasm
** Multiple Sclerosis
** Non traumatic brain hemorrhage
** Seizures
** Stroke (suspected stroke, TIA)
** Tumor
** Vascular Malformation**


Contrast Media Summary

Information under section A above is included in this coding and billing article solely for the purpose to provide guidance for dates of service prior to 01/01/2007. Information under section B above is included in this coding and billing article solely for the purpose to provide rationale for understanding the billing changes beginning with the dates of service after 01/01/2007. To summarize, based on new CMS instructions in section B above, there were two changes made effecting billing MRI contrast.

The second (B2) states that as of 01/01/2007 Medicare will pay separately for the contrast medium used in performing any MRI services that require the use of contrast. If the service is Procedure codes 70553, 72156, 72157, or 72158, the A9579 should be billed for the standard amount of material AND ALSO the additional amount for the increased dose.

MRI procedure codes (70549, 70553, 70559, 71552, 72197, 73220, 73223, 73720, 73723, and  74183) include a MRI sequence performed without contrast media, followed by a MRI sequence performed with contrast media, and followed by MRI further sequences. The contrast medium used may be billed separately. No addition payment is made by Medicare for the MRI procedure
performed in the further sequences phase. The above listed procedures should be reported only once per day.


Magnetic Resonance Imaging (MRI) Procedures

Carriers do not make additional payments for three or more MRI sequences. The RVUs reflect payment levels for two sequences.

The TC RVUs for MRI procedures that specify “with contrast” include payment for paramagnetic contrast media. Carriers do not make separate payment under code A4647.

A diagnostic technique has been developed under which an MRI of the brain or spine is first performed without contrast material, then another MRI is performed with a standard (0.1mmol/kg) dose of contrast material and, based on the need to achieve a better image, a third MRI is performed with an additional double dosage (0.2mmol/kg) of contrast material. When the high-dose contrast technique is utilized, carriers:

• Do not pay separately for the contrast material used in the second MRI procedure;

• Pay for the contrast material given for the third MRI procedure through supply code Q9952, the replacement code for A4643, when billed with Procedure codes 70553, 72156, 72157, and 72158;

• Do not pay for the third MRI procedure. For example, in the case of an MRI of the brain, if Procedure code 70553 (without contrast material, followed by with contrast material(s) and further sequences) is billed, make no payment for Procedure code 70551 (without contrast material(s)), the additional procedure given for the purpose of administering the double dosage, furnished during the same session. Medicare does not pay for the third procedure (as distinguished from the contrast material) because the Procedure definition of code 70553 includes all further sequences; and

• Do not apply the payment criteria for low osmolar contrast media in §30.1.2 to billings for code Q9952, the replacement code for A4643.

Effective January 1, 2007

With the implementation for calendar year 2007 of a bottom-up methodology, which utilizes the direct inputs to determine the practice expense (PE) relative value units (RVUs), the cost of the contrast media is not included in the PE RVUs. Therefore, a separate payment for the contrast media used in various imaging procedures is paid. In addition to the Procedure code representing the imaging procedure, separately bill the appropriate HCPCS “Q” code (Q9945 – Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service.

Documentation Requirements

    The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, and interpretive report and copies of all images obtained. The computerized data with image reconstruction should also be maintained.

    The medical record must contain documentation, including a written or electronic request for the procedure which fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures. This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available upon request.

    When a CT scan and MRI are performed on the same day for the same anatomical area, the medical record must clearly reflect the medical necessity for performing both tests.

    Rules for Testing Facility to Furnish Additional Tests:

    If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

        The testing center performs the diagnostic test ordered by the treating physician/practitioner;
        The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;
        Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;
        The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and
        The interpreting physician at the testing facility documents in his/her report why additional testing was done.


    Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests:
    The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

    Test Design:
    Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness or tomographic sections acquired, use or non-use of contrast media).

    If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his order for the test.

ICD-10 Codes that Support Medical Necessity

ICD-10 CODE DESCRIPTION

A02.21 Salmonella meningitis
A06.6 Amebic brain abscess
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A17.9 Tuberculosis of nervous system, unspecified
A18.01 Tuberculosis of spine
A18.03 Tuberculosis of other bones
A18.2 Tuberculous peripheral lymphadenopathy
A18.50 Tuberculosis of eye, unspecified
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A27.81 Aseptic meningitis in leptospirosis
A32.0 Cutaneous listeriosis
A32.11 Listerial meningitis
A32.12 Listerial meningoencephalitis
A32.7 Listerial sepsis
A32.81 Oculoglandular listeriosis
A32.82 Listerial endocarditis
A32.89 Other forms of listeriosis
A32.9 Listeriosis, unspecified
A39.0 Meningococcal meningitis
A39.1 Waterhouse-Friderichsen syndrome
A39.2 Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A39.50 Meningococcal carditis, unspecified
A39.51 Meningococcal endocarditis
A39.52 Meningococcal myocarditis
A39.53 Meningococcal pericarditis
A39.81 Meningococcal encephalitis
A39.82 Meningococcal retrobulbar neuritis
A39.83 Meningococcal arthritis
A39.84 Postmeningococcal arthritis
A39.89 Other meningococcal infections
A39.9 Meningococcal infection, unspecified
A41.9 Sepsis, unspecified organism
A50.30 Late congenital syphilitic oculopathy, unspecified
A50.32 Late congenital syphilitic chorioretinitis
A50.39 Other late congenital syphilitic oculopathy
A50.40 Late congenital neurosyphilis, unspecified
A50.41 Late congenital syphilitic meningitis
A50.42 Late congenital syphilitic encephalitis
A50.43 Late congenital syphilitic polyneuropathy
A50.44 Late congenital syphilitic optic nerve atrophy
A50.45 Juvenile general paresis
A50.49 Other late congenital neurosyphilis
A50.51 Clutton's joints
A50.52 Hutchinson's teeth
A50.53 Hutchinson's triad
A50.54 Late congenital cardiovascular syphilis
A50.55 Late congenital syphilitic arthropathy
A50.56 Late congenital syphilitic osteochondropathy
A50.57 Syphilitic saddle nose
A50.59 Other late congenital syphilis, symptomatic
A51.41 Secondary syphilitic meningitis
A51.49 Other secondary syphilitic conditions
A52.00 Cardiovascular syphilis, unspecified
A52.10 Symptomatic neurosyphilis, unspecified
A52.11 Tabes dorsalis
A52.12 Other cerebrospinal syphilis
A52.13 Late syphilitic meningitis
A52.14 Late syphilitic encephalitis
A52.15 Late syphilitic neuropathy
A52.16 Charcot's arthropathy (tabetic)
A52.17 General paresis
A52.19 Other symptomatic neurosyphilis
A52.2 Asymptomatic neurosyphilis
A52.3 Neurosyphilis, unspecified
A54.81 Gonococcal meningitis
A80.0 Acute paralytic poliomyelitis, vaccine-associated
A80.1 Acute paralytic poliomyelitis, wild virus, imported
A80.2 Acute paralytic poliomyelitis, wild virus, indigenous
A80.30 Acute paralytic poliomyelitis, unspecified
A80.39 Other acute paralytic poliomyelitis
A80.4 Acute nonparalytic poliomyelitis
A80.9 Acute poliomyelitis, unspecified
A81.00 Creutzfeldt-Jakob disease, unspecified
A81.01 Variant Creutzfeldt-Jakob disease
A81.09 Other Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
A81.81 Kuru
A81.82 Gerstmann-Straussler-Scheinker syndrome
A81.83 Fatal familial insomnia
A81.89 Other atypical virus infections of central nervous system
A81.9 Atypical virus infection of central nervous system, unspecified
A82.0 Sylvatic rabies
A82.1 Urban rabies
A82.9 Rabies, unspecified
A83.0 Japanese encephalitis
A83.1 Western equine encephalitis
A83.2 Eastern equine encephalitis


Group 2 Codes:

ICD-10 CODE DESCRIPTION

F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder
F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction
F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder
F19.220 Other psychoactive substance dependence with intoxication, uncomplicated
F19.222 Other psychoactive substance dependence with intoxication with perceptual disturbance
F19.230 Other psychoactive substance dependence with withdrawal, uncomplicated
F19.231 Other psychoactive substance dependence with withdrawal delirium
F19.232 Other psychoactive substance dependence with withdrawal with perceptual disturbance
F19.250 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with delusions
F19.251 Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder with hallucinations
F19.280 Other psychoactive substance dependence with psychoactive substance-induced anxiety disorder
F19.281 Other psychoactive substance dependence with psychoactive substance-induced sexual dysfunction
F19.288 Other psychoactive substance dependence with other psychoactive substance-induced disorder
F32.81 Premenstrual dysphoric disorder
F32.89 Other specified depressive episodes
F53 Puerperal psychosis
G83.5 Locked-in state
G92 Toxic encephalopathy

Indication and Limitation

Indications

Extra-axial tumors, A-V malformations, cavernous hemangiomas, small intracranial aneurysms, cranial nerve lesions, demyelination disorders including multiple sclerosis, lesions near dense bone, acoustic neuromas, pituitary lesions, and brain radiation injuries;

Developmental abnormalities of the brain including neuroectodermal dysplasia;

Subacute central nervous system hemorrhage or hematoma;

Acute cerebrovascular accidents;

Complex partial seizures, seizures refractory to therapy, temporal lobe epilepsy, or other atypical seizure disorders;

Patients whose presentation indicates a focal problem or who have had a recent significant change in neurologic symptomology;

Brain infections;

Conditions where soft tissue contrast is necessary;

When bone artifacts limit CT

Coronal, coronosagittal or parasagittal images are desired; and/or

Procedures in which iodinated contrast material are contraindicated.

Limitations

MRI is usually not the procedure of choice in patients who have acute head trauma, acute intracranial bleeding, for investigation of skull fracture or other bone abnormality, or as follow-up for hydrocephalus.

For 2007 CPT codes 70554 and 70555 have been added. Coverage for these CPT codes is not covered in this LCD.

Certain uses of MRI are considered investigational, and are therefore, not covered by Medicare. These include:

spectroscopy;
cortical bone and calcifications imaging;
procedures involving spatial resolution of bone or calcifications.

Three dimension reconstruction of MRI of the Brain (CPT code 76376 or 76377) is expected to be utilized rarely. CPT 76376 or 76377 are not an appropriate part of every MRI examination.


For patients with cardiac pacemakers or metallic clips on vascular aneurysms, please refer to the National Coverage Determination (NCD) for Magnetic Resonance Imaging (220.2) for special provisions of coverage.

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