When a contrast-enhanced magnetic resonance imaging (MRI) study is performed on the same day as an unenhanced study of the same organ or body area, the appropriate combination code should be used. For example, when an MRI of the brain without contrast material (70551) is followed by an MRI of the brain with contrast material (70552), use combination code 70553.

Payment is made for contrast material in addition to the MRI procedure. The diagnostic imaging agent/contrast material used in conjunction with an eligible imaging procedure is eligible when administered by the health care professional in a setting other than a hospital or a skilled facility.

When charges for additional acquisitions, cuts, slices, etc., are billed separately, the charges are combined and paid under the appropriate code for the study performed.

When more than one organ in an anatomic area is studied on the same day (for example, liver and gallbladder), payment is limited to one MRI study of that anatomic area.

If more than one anatomic area is studied (for example, the brain and abdomen), payment is made for each anatomic area studied.

When bilateral studies of the temporomandibular joint (TMJ) are reported, payment is made for each study.

When bilateral extremity studies are performed (for example, right and left arms or right and left legs) payment is made for each study.

When different areas of the same extremity are performed (for example, left humerus and left forearm or right knee and right ankle, etc.), payment is made for both studies.

All other studies are reimbursed as one study. In all cases, clinical information documenting the medical necessity for each MRI study on the same day must be maintained in the patient’s record and available for review upon request.

When both MRI and a computed tomography (CT) scan are performed on the same day for the same anatomic area, payment should be made for the CT scan. The MRI may only be paid if supporting documentation is submitted to establish medical necessity for both studies. Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Eye x-rays performed prior to an MRI
When eye x-rays (code 70030) are performed to evaluate a patient for metal or metallic fragments in the eye prior to an MRI, the eye x-ray is only considered medically necessary and covered for patients with a known, documented or suspected contact with magnetic metal or metallic fragments.

Cardiac MRI for velocity flow mapping (code 75565) 
Code 75565 (Cardiac MRI for velocity flow mapping) is designated as an add-on code. Add-on codes must be reported with the primary procedure with which it is performed. As such, code 75565 should be reported on the same claim with codes 75557, 75559, 75561 or 75563. When reported alone, that is, without the appropriate primary cardiac MRI code, the add-on code (75565) will be denied. A provider cannot bill the member for the denied service in this situation.  

In addition, cardiac MRI with velocity flow mapping (code 75565) is only considered eligible for the following conditions. (This guideline applies to code 75565 even when it is reported with codes 75557, 75559, 75561 or 75563.)

• Evaluation of chest pain
  • intermediate pre-test probability of CAD; or
  • uninterpretable ECG or unable to exercise; or
  • no ECG changes and serial enzymes negative; or
  • uninterpretable or equivocal stress test
• Suspected coronary anomalies
• Congenital heart disease or other anomalies of the coronary circulation, great vessels, cardiac chambers and valves
• Cardiomyopathies
• Native and/or prosthetic valves
• Myocarditis or myocardial infarction
• Cardiac mass (suspected tumor or thrombus)
• Pericardial conditions (such as pericardial mass or constrictive pericarditis, complications of cardiac surgery), myocardial necrosis
• Suspected aortic dissection or thoracic aortic aneurysm
• Pulmonary venous anatomy prior to invasive radiofrequency ablation for atrial fibrillation
• Noninvasive coronary vein mapping prior to placement of biventricular pacemaker
• Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization

Cardiac MRI for flow velocity (code 75565) will be denied as not medically necessary when reported with a diagnosis or condition other than those listed. This guideline applies even when code 75565 is reported with a primary cardiac MRI procedure code.

Services that do not meet the medical necessity criteria documented in this policy will be considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Description

Magnetic resonance imaging, also referred to as nuclear magnetic resonance (NMR), is a noninvasive diagnostic imaging modality. The technique uses the interaction of a magnetic field and radiofrequency waves to generate, with computer assistance, an image of an area of the body.

For information on MRI of the breast see Medical Policy Bulletin X-44.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical Policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

Hendel RC, Patel MR, et al. The American College of Cardiology Foundation in conjunction with the American College of Radiology (ACR), Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology (ASNC), North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions and the Society of Interventional Radiology 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. Journal of the American College of Cardiology. 2006;48(7):1475-1497.

Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E. Standardized Cardiovascular Magnetic Resonance Imaging (CMR) Protocols, Society for Cardiovascular Magnetic Resonance: Board of Trustees Task Force on Standardized Protocols. Journal of Cardiovascular Magnetic Resonance. 2008;10:35.

Rathi VK, Doyle M, Yamrozik J, Williams RB, et al. Routine Evaluation of Left Ventricular Diastolic Function by Cardiovascular Magnetic Resonance: A Practical Approach. Journal of Cardiovascular Magnetic Resonance. 2008;10:36.

Marsan NA, Westenberg JJM, et al. Comparison Between Tissue Doppler Imaging and Velocity-Encoded Magnetic Resonance Imaging for Measurement of Myocardial Velocities, Assessment of Left Ventricular Dyssnchrony, and Estimation of Left Ventricular Filling Pressures in Patients With Ischemic Cardiomyopathy. The American Journal of Cardiology. 2008;102(10):1366-1372.

Walsh TF, Hundley G, Assessment of Ventricular Function with Cardiovascular Magnetic Resonance. Cardiology Clinics. 2007;25:15-33.

Ozturk C, Derbyshire JA, McVeigh ER. Estimating Motion from MRI Data. Proc IEEE Inst Electr Electron Eng. 2003 October;9(10):1627-1648. (Author manuscript available in PMC 2008 October 28) Accessed November 2008.