Wednesday, May 18, 2016

Payment rules for Magnetic Resonance Imaging (MRI) Procedures

Effective September 28, 2009

The Centers for Medicare & Medicaid Services (CMS) finds that the non-coverage of magnetic resonance imaging (MRI) for blood flow determination is no longer supported by the available evidence. CMS is removing the phrase “blood flow measurement” and local Medicare contractors will have the discretion to cover (or not cover).

Consult Publication (Pub.) 100-03, National Coverage Determinations (NCD) Manual, chapter 1, section 220.2, for specific coverage and non-coverage indications associated with MRI and MRA (Magnetic Resonance Angiography).

Prior to January 1, 2007

A/B MACs (B) do not make additional payments for three or more MRI sequences. The relative value units (RVUs) reflect payment levels for two sequences.

The technical component (TC) RVUs for MRI procedures that specify “with contrast” include payment for paramagnetic contrast media. A/B MACs (B) 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, 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

• 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.

Effective February 24, 2011

Medicare will allow for coverage of MRI for beneficiaries with implanted PMs or cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare-approved clinical study as described in section 220.C.1 of the NCD manual.

Effective July 7, 2011

Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an MRI environment as described in section 220.2.C.1 of the NCD Manual.

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