Post #29 Use the correct MRI Extremity codes to Avoiding Peer-to-Peer calls

While working as a medical director for a Radiology Benefits Manager (RBM), I was amazed how some requests were denied simply because the wrong imaging code had been submitted. MRIs of the shoulder or knee may be needed by the provider, but the office staff asked for an MRI of the humerus or femur by mistake. Denials resulted over and over again with the very same reason by the same requesting doctor. While performing peer-to-peer calls with these providers, I often tried to teach them a few coding tips, but time was limited and physicians needed to get back to their patients. Coding for imaging studies of the musculoskeletal (MS) system falls into this coding trap. This post will provide a mini-coding course I hope will put a stop to many of your peer-to-peer calls.

Musculoskeletal Coding Rule # 1 – MRI shoulder codes are as simple as 1,2,3

CPT procedure coding consists of a 5-digit number for each service. The first digit refers to the broad category of services. You already are aware that the 9XXXX services are physician services such as office visits and hospital visits.

All imaging services begin with the digit “7” as the code for plain x-rays, ultrasounds, doppler, CT scans, and MRIs.

The 5th digit in the code refers to specific contrast details of the procedure. As an example, for MRI of the shoulder, the last digit 1 refers to the MRI without contrast, the last digit 2 refers to the MRI with contrast, and the last digit 3 refers to an MRI without and with contrast.

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The codes above are the most common MRI scans requested by providers to image the upper extremity, but those 3 codes are also used for sites other than the shoulder. The exact same codes may be used to refer to two other joints in the upper extremity: the elbow and the wrist. So if your office requests a “73221”, there is no way to tell if the imaging desired is for an MRI of the shoulder, the elbow, or the wrist without also looking at additional clinical information.

There are 3 additional CPT codes that correspond to the upper extremity, but they image those body parts between the joints. For example, 73218 (without contrast), 73219 (with contrast) and 73220 (without and with contrast) are the codes that may refer to the humerus or the radius/ulna or the hand/fingers. If the entire humerus needs to be viewed, these codes should be used instead of the joint codes. The formal name of these services are MRI Upper Extremity ,other than joint. This may be a bit confusing because the MRI of the hand, with its dozens of joints, falls into the category of “other than joint.”

As with upper extremity joint coding, there is no way to tell if the imaging desired is for an MRI of the humerus, forearm, or hand unless the clinical information specifies.

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Additional Tips on MRI Coding for the Upper Extremity

Often an orthopedic surgeon suspects a shoulder labral tear (SLAP, ALPSA, HAGL or a bucket handle tear) and requests an imaging study that requires MRI dye be injected directly into the joint. This is called an MR arthrogram and is coded as an MRI upper extremity, joint, with contrast (73222).

Approval for MRI scan of the shoulder is often withheld until patients have been unsuccessfully treated for 6-weeks with conservative treatment. There are exceptions to this rule such as SLAP lesions, acute shoulder injuries and acute tendon ruptures, since acute surgery may be required. See Post #27 for the complete list of these lesions that do not require conservative therapy.

Most MRI imaging of the MS system is performed without contrast. Exceptions include MRI with contrast (also called MR-arthrogram) for SLAP lesions described above. Other cases such as suspected tumors, osteomyelitis, soft tissue infection, and inflammatory arthritis may be performed as a dual study (without and with contrast).

MRI coding for the lower extremity (joints and other than joints)

Coding for the lower extremity exactly parallels coding for the upper extremity. For example, the last digit “1” refers to the MRI without contrast, the last digit “2” refers to the MRI with contrast, and the last digit “3” refers to an MRI without and with contrast.

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Usually the codes above are the most common MRI scans requested to image the lower extremity, but those 3 codes are all used to refer to the hip, knee, or ankle. So if your office requests a “73721”, there is no way to tell if the imaging desired is for an MRI (without contrast) of the hip, knee, or ankle without also looking at additional clinical information.

There are 3 more CPT codes that correspond to the lower extremity, but they image the body parts between the joints. For example 73718 (without contrast), 73719 (with contrast) and 73720 (without and with contrast) are the 3 codes that refer to the femur or the tibia/fibula or the foot/toes. If the entire femur needs to be viewed, these codes should be used instead of the joint codes, and they are called MRI Lower Extremity other than joint. This may be a bit confusing because the MRI of the foot, with its dozens of joints, falls into the category of “other than joint.”

As with joint coding, there is no way to tell if the imaging desired is for an MRI of the femur, tibia/fibula, or foot unless the clinical information specifies.

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Additional MRI Tips on Coding for the Lower Extremity

Often an orthopedic surgeon suspects a lower extremity lesion that requires an MRI with contrast (MR arthrogram), which is coded as an MRI lower extremity, joint, with contrast (73722). Refer to the guidelines for a listing of these clinical indications.

Many lower extremity lesions may be evaluated with MRI scan after the patient has unsuccessfully been treated for 6-weeks with conservative treatment. See Post #27 for the complete list of these lesions that do not require conservative therapy.

Most MRI imaging of the MS system is performed without contrast. Exceptions include MRI with contrast (arthrogram) for some lesions. Suspected tumors, osteomyelitis, soft tissue infection, and inflammatory arthritis, may be evaluated as a dual study (without and with contrast). These exceptions apply when requesting either joints or other than joint. As noted in a previous post, advanced imaging (either MRI or CT scan) authorization almost always requires a recent prior plain x-ray.

Lesson #29: A common reason for denials and peer-to-peer phone conversations is incorrect coding for advanced imaging. If uncertain as to which test and which contrast modality would by approved, refer to the evidence-based guidelines found on radiology benefits management websites.