73721 - Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material average fee amount - $230 -$240
70336 - Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
73221 - Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)
73222 - Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)
73223 - Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences
73722 - Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)
73723 - Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences
Diagnostic examinations of joint(s) performed on Magnetic Resonance Imaging (MRI) units are covered if they are:
- Reasonable and medically necessary for the individual patient.
- Performed on a unit that has received federal FDA approval. Such a unit(s) must be operated within the parameters specified by that approval.
- Compliant with ACR quality standards. Note: Refer to the guidelines listed below for office-based MRI.
Office-Based MRI
In order to maintain appropriate quality in office-based MRI, the MRI Accreditation Program Requirements serve as a pertinent performance benchmark, and, using such as a reference document, it is intended that the following guidelines be followed with respect to:
Staff Competency
A provider who performs the interpretation and written report of an MRI of a joint (professional component) must possess the knowledge, skills, training and experience minimally necessary for this component of the service. Medicare coverage of these services is conditional on the competence of the individual who performs and interprets the service. Medicare expects that any provider who seeks and receives payment for the professional components of these radiographic services will be prepared to substantiate his training and/or experience if asked by Medicare to do so. Numerous pathways for achieving and maintaining competency for providing these services by physicians and technologists exist.
The qualified physician’s continuing education should be in accordance with the ACR Practice Guideline for Continuing Medical Education (CME) or should include CME in MRI as is appropriate to the physician’s practice needs.Technologists practicing MRI scanning should be licensed in the jurisdiction in which he/she practices, if state licensure for MRI technologists exists. The continuing education for a technologist should be 15 hours of Category A CME in MRI every three years.
An MRI of a joint may be personally performed by a physician or a technologist. When performed by a technologist,one of the following standards must be met:
- Facility must be accredited for MRI by the
- For testing performed in non-ACR accredited office facilities, the technologist must have received credentials in MRI technology as a Certified Radiologic Technologist (CRT) from the American Registry of Radiologic Technologists (ARRT).
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Magnetic Resonance Imaging (MRI) is a non-invasive imaging technique used for a variety of diagnostic visualizations.
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.
MRI can enhance diagnostic sensitivity and facilitate early diagnosis in a limited number of articular disorders and is indicated in selected circumstances when conventional radiography is not adequate.
MRI of any joint of the lower extremities (73721-73723) will be considered medically reasonable and necessary under the following conditions:
· Avascular necrosis;
· Osteomyelitis;
· Intraarticular derangement; and
· Villonodular synovitis.
Contraindications and non-covered uses
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.
· Patients with a viable pregnancy.
· Patients with devices containing ferromagnetic materials.
· Patients who are claustrophobic.
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.
Quality Control and Quality Assurance
There should be a well-documented office protocol for performing continuous quality control testing of instrumentation in tandem with periodic preventive maintenance, which is also properly documented in service records maintained by the MRI site. In addition, appropriately documented physician peer-review activities should be an integral portion of the staff competency guidelines discussed above.
The choice of the appropriate imaging modality should be determined at an individual level. In some cases, MRI may be an appropriate initial choice; in others, standard X-rays should be used for the initial evaluation. Generally, MRI of a joint is considered medically necessary when the following disorders are present or suspected and/or the necessary information is not available from standard X-rays. Joint MRIs are indicated for the following clinical conditions:
- Tumors/masses or swelling involving or contiguous to a joint.
- Rotator cuff tears or impingement.
- Joint instability, deformities or internal derangement.
- Intra-articular osteocartilaginous body(ies).
- Occult joint injury, e.g., osteochondral injury.
- Suspected nerve entrapment or mass close to a joint.
- Suspected ligament or tendon injury.
- Kienbock’s disease of the wrist.
- Bone abnormalities of a joint related to soft tissue abnormalities.
- Occult Avascular Necrosis (AVN) or follow-up of this condition.
- Acute joint injuries.
- Actual or suspected infection or inflammation on joints or surrounding structures.
- Effect of other single or multiple system, non-joint disorders on joints and surrounding structures.
- Pain/other sensory disturbances in joints or surrounding structures.
- Weakness/other motor disturbances in joints or surrounding structures.
- Decreased range of motion; stiffness, popping/clicking, instability or discoordination related to joints and surrounding structures.
- Characterization of an abnormal finding in joints or surrounding structures detected on another test.
- Meniscal and/or ligamentous tears.
- Tendinopathy.
- Assessment of joints and surrounding structures in preparation for an interventional procedure.
Usually an MRI of a joint is performed when standard X-rays are inconclusive and the patient may have failed a treatment regimen for a disorder clinically diagnosed from medical history and examination. MRIs of a joint are generally not indicated when a surgical exploration of the joint (arthroscopic or open) will be performed regardless of the results of the MRI, unless the MRI results are to be used to provide information for planning the optimal surgical approach.
The clinical necessity of performing a joint MRI must be noted in the medical record or easily inferred from the medical record. Screening imaging or unnecessary duplication of imaging is not considered medically necessary.
There are relative contraindications to MRI scanning. These include cardiac pacemakers, ferromagnetic clips, intraocular metal and cochlear implants. MRI scanning under these circumstances is only covered when the medical situation is clearly explained.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 83X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
CPT/HCPCS Codes
Note:
|
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
|
70336©
|
Magnetic image, jaw joint
|
73221©
|
Mri joint upr extrem w/o dye
|
73222©
|
Mri joint upr extrem w/ dye
|
73223©
|
Mri joint upr extr w/o&w dye
|
73721©
|
Mri joint of lwr extre w/o d
|
73722©
|
Mri joint of lwr extr w/dye
|
73723©
|
Mri joint lwr extr w/o&w dye
|
Procedure code 73221 - STUDY CPT DESCRIPTION INDICATIONS FOR EXAM OR STUDY CONTRAST REQUIRED? SPECIALTY
MRI EXTREMITY JOINT:
UPPER Hand Wrist Elbow Shoulder SC Joint
LOWER Foot Ankle Knee Hip
MRI Joint without contrast:
Upper Extremity
Lower Extremity
Arthritis Meninscal tear
Avascular necrosis (AVN) Muscle tear
Stress fracture Ligament tear
Internal derangement Cartilage tear
Joint pain Ostochondritis dissecans (OCD)
Labral tear
No
Orthopedic
73221 MRI Upper Extremity Joint without Gadolinium: Shoulder See also: Wrist and Hand; Elbow
I. Chronic joint pain with negative x-ray1,2
A. Incomplete resolution with conservative medical management [One of the following]
1. Continued pain after treatment with anti-inflammatory medication and physical therapy for at least 4 weeks
2. Symptoms worsening while under treatment
II. Suspected intra-articular loose body and recent x-ray [One of the following]1
A. Joint pain
B. Locking
C. Clicking
III. Suspected or known avascular necrosis (osteonecrosis, OCD, AVN, osteochondritis dissecans) with pain and recent x-ray which may be either negative or non-diagnostic or diagnostic of AVN but additional information is needed to determine management [One risk factor and one selection from history or physical finding or clarification of findings on other imaging]
A. Risk factors and pain [One of the following]
1. Steroid use
2. Sickle cell disease
3. Excessive alcohol use
4. HIV infection
5. SLE
6. Renal transplant
7. Trauma [One of the following]
a. Fracture
b. Dislocation
8. Coagulopathy
9. Bisphosphonate use
10. Smoking
11. Pancreatitis
12. Gaucher’s disease
B. Physical findings [One of the following]
1. Catching
2. Locking
3. Clicking
4. Grinding
5. Crepitus
6. Stiffness
7. Tenderness over the shoulder
8. Flexion contractures
IV. Suspected fracture with negative x-ray3,4 [One of the following]
1. Negative x-ray 10-14 days after the onset of pain (If this is the only x-ray then the need for an initial x-ray is waived.)
B. Child abuse
C. Bone scan positive but not specific for fracture
D. Osteoporosis on bone density or long term steroid use
V. Suspected acute rotator cuff tear with or without acromial spurs on x-ray (if performed) and incomplete resolution with conservative medical management consisting of treatment with anti-inflammatory medication and physical therapy for at least 4 weeks or symptoms worsening during trial of conservative management [One symptom and one finding on examination) or C]5
A. Symptoms [One of the following]
1. Pain especially with overhead activities such as reaching or combing hair
2. Pain increases when sleeping of the affected side
3. Inability to use the arm or lift the arm
B. Findings on examination [One of the following]
1. Weakness on examination
2. Subacromial tenderness
3. Positive Apley’s scratch test
4. Positive Neer sign
5. Positive apprehension test
6. Positive drop arm test
7. Positive empty can sign
8. Positive relocation sign
9. Positive sulcus sign
C. Recurrent pain and finding(s) in B above following surgery
VI. Suspected chronic rotator cuff tendinitis2 with or without acromial spurs (if performed) and incomplete resolution with conservative medical management consisting of treatment with anti-inflammatory medication and physical therapy for at least 4 weeks or symptoms or findings worsening during trial of conservative management [(One symptom and one finding on examination) or C]
A. Symptoms [One of the following]
1. Dull aching in the shoulder, which may interfere with sleep
2. Severe pain when the arm is actively abducted into an overhead position such as throwing, reaching or combing hair
B. Findings on examination [One of the following]
1. Weakness on examination
2. Subacromial tenderness
3. Positive Apley’s scratch test
4. Positive Neer sign
5. Positive apprehension test
6. Positive drop arm test
7. Positive empty can sign
8. Positive relocation sign
9. Positive sulcus sign
C. Recurrent pain following surgery and finding(s) in B above
VII. Suspected labral tear or SLAP lesion or Bankart lesion [One of the following] (MR arthrogram MRI with contrast is preferred)1,6-8
A. Pain interferes with the smooth functioning of the shoulder
B. Discomfort on forced external rotation at 90 degrees of abduction
C. A “pop” or “click” on forced external rotation
D. Discomfort on forced horizontal adduction of the shoulder
E. Weakness in the rotator cuff muscles on examination
F. Decreased range of motion
G. Pain with overhead activity
VIII. Bicipital tendonitis (biceps tendonitis)9,10 incomplete resolution with conservative medical management consisting of treatment with antiinflammatory medication and physical therapy for at least 4 weeks or symptoms or findings worsening during trial of conservative management [Both of the following]
A. Symptoms [One of the following]
1. Anterior shoulder pain
2. Pain with overhead lifting or overhead activity
B. Findings on exam [One of the following]
1. Tenderness over the bicipital groove on examination
2. Positive Yergason’s test
3. Positive Speed’s test
4. Pain increases with flexion of the shoulder against resistance
IX. Muscle tear [One of the following]
A. Symptoms [One of the following]
1. Pain and swelling over the muscle
2. Bruising over the muscle
3. Bulge
4. Defect in the muscle
X. Biceps tendon tear9-11 with incomplete resolution with at least 4 weeks of conservative medical management consisting of ice, anti-inflammatory medication, rest and physical therapy or worsening of symptoms during trial of conservative management
A. Symptoms [One of the following]
1. Sudden sharp pain in the upper arm
2. Pop or snap can be heard
3. Cramping of upper arm over the biceps with use of the arm
4. Bruising of the upper arm
5. Pain or tenderness
6. Weakness of the shoulder or elbow on examination
7. Difficulty with pronation and/or supination
8. Bulge in the upper arm
9. Defect over the muscle
XI. Rotator cuff impingement syndrome1,12 or shoulder bursitis with or without an x-ray showing either acromial spur, calcification of the coracoacromial ligament or acromioclavicular arthritis and incomplete resolution with at least 4 weeks of ice, rest, physical therapy and anti-inflammatory medication or steroid injections or symptoms worsening while on conservative management [One of the following]
A. Symptoms
1. Shoulder pain increased by overhead movements
2. Pain interfering with sleep when lying on the affected side
XII. Soft tissue mass including soft tissue sarcoma with negative x-ray (MRI without and with contrast is strongly preferred except for the evaluation of a ganglion [See below] and a lipoma for which CT is preferred) [One of the following]13-17
A. Palpable soft tissue mass not explained by US
B. Prominent calcifications on plain film
C. Follow up of spontaneous bleed into the soft tissues
D. Increasing size of known soft tissue mass
E. Recent trauma, suspected hematoma negative US
F. Suspected ganglion (most common in hand and wrist when they occur in the upper extremity) which fails to respond to aspiration or recurs after aspiration or is solid on transillumination or ultrasound
G. Suspected lipoma must have non diagnostic CT
H. Soft tissue sarcoma of the extremity [One of the following]
1. Initial staging
2. Follow up after surgery to establish a new baseline
3. Post operative imaging after primary therapy for any stage tumor
4. Surveillance for local recurrence in an asymptomatic individual [One of the following]
a. 3-6 months for 5 years
b. Annually years 5-10
5. Suspicion of local recurrence [One of the following]
a. New or recurrent symptoms
b. New or recurrent mass
c. New changes on x-ray or other imaging
XIII. Child abuse
XIV. Soft tissue abscess with negative ultrasound and tender or warm or erythematous area – See MRI without and with contrast, CPT code 73223
ICD-9-CM Codes That Support Medical Necessity
I. Chronic joint pain with negative x-ray1,2
A. Incomplete resolution with conservative medical management [One of the following]
1. Continued pain after treatment with anti-inflammatory medication and physical therapy for at least 4 weeks
2. Symptoms worsening while under treatment
II. Suspected intra-articular loose body and recent x-ray [One of the following]1
A. Joint pain
B. Locking
C. Clicking
III. Suspected or known avascular necrosis (osteonecrosis, OCD, AVN, osteochondritis dissecans) with pain and recent x-ray which may be either negative or non-diagnostic or diagnostic of AVN but additional information is needed to determine management [One risk factor and one selection from history or physical finding or clarification of findings on other imaging]
A. Risk factors and pain [One of the following]
1. Steroid use
2. Sickle cell disease
3. Excessive alcohol use
4. HIV infection
5. SLE
6. Renal transplant
7. Trauma [One of the following]
a. Fracture
b. Dislocation
8. Coagulopathy
9. Bisphosphonate use
10. Smoking
11. Pancreatitis
12. Gaucher’s disease
B. Physical findings [One of the following]
1. Catching
2. Locking
3. Clicking
4. Grinding
5. Crepitus
6. Stiffness
7. Tenderness over the shoulder
8. Flexion contractures
IV. Suspected fracture with negative x-ray3,4 [One of the following]
1. Negative x-ray 10-14 days after the onset of pain (If this is the only x-ray then the need for an initial x-ray is waived.)
B. Child abuse
C. Bone scan positive but not specific for fracture
D. Osteoporosis on bone density or long term steroid use
V. Suspected acute rotator cuff tear with or without acromial spurs on x-ray (if performed) and incomplete resolution with conservative medical management consisting of treatment with anti-inflammatory medication and physical therapy for at least 4 weeks or symptoms worsening during trial of conservative management [One symptom and one finding on examination) or C]5
A. Symptoms [One of the following]
1. Pain especially with overhead activities such as reaching or combing hair
2. Pain increases when sleeping of the affected side
3. Inability to use the arm or lift the arm
B. Findings on examination [One of the following]
1. Weakness on examination
2. Subacromial tenderness
3. Positive Apley’s scratch test
4. Positive Neer sign
5. Positive apprehension test
6. Positive drop arm test
7. Positive empty can sign
8. Positive relocation sign
9. Positive sulcus sign
C. Recurrent pain and finding(s) in B above following surgery
VI. Suspected chronic rotator cuff tendinitis2 with or without acromial spurs (if performed) and incomplete resolution with conservative medical management consisting of treatment with anti-inflammatory medication and physical therapy for at least 4 weeks or symptoms or findings worsening during trial of conservative management [(One symptom and one finding on examination) or C]
A. Symptoms [One of the following]
1. Dull aching in the shoulder, which may interfere with sleep
2. Severe pain when the arm is actively abducted into an overhead position such as throwing, reaching or combing hair
B. Findings on examination [One of the following]
1. Weakness on examination
2. Subacromial tenderness
3. Positive Apley’s scratch test
4. Positive Neer sign
5. Positive apprehension test
6. Positive drop arm test
7. Positive empty can sign
8. Positive relocation sign
9. Positive sulcus sign
C. Recurrent pain following surgery and finding(s) in B above
VII. Suspected labral tear or SLAP lesion or Bankart lesion [One of the following] (MR arthrogram MRI with contrast is preferred)1,6-8
A. Pain interferes with the smooth functioning of the shoulder
B. Discomfort on forced external rotation at 90 degrees of abduction
C. A “pop” or “click” on forced external rotation
D. Discomfort on forced horizontal adduction of the shoulder
E. Weakness in the rotator cuff muscles on examination
F. Decreased range of motion
G. Pain with overhead activity
VIII. Bicipital tendonitis (biceps tendonitis)9,10 incomplete resolution with conservative medical management consisting of treatment with antiinflammatory medication and physical therapy for at least 4 weeks or symptoms or findings worsening during trial of conservative management [Both of the following]
A. Symptoms [One of the following]
1. Anterior shoulder pain
2. Pain with overhead lifting or overhead activity
B. Findings on exam [One of the following]
1. Tenderness over the bicipital groove on examination
2. Positive Yergason’s test
3. Positive Speed’s test
4. Pain increases with flexion of the shoulder against resistance
IX. Muscle tear [One of the following]
A. Symptoms [One of the following]
1. Pain and swelling over the muscle
2. Bruising over the muscle
3. Bulge
4. Defect in the muscle
X. Biceps tendon tear9-11 with incomplete resolution with at least 4 weeks of conservative medical management consisting of ice, anti-inflammatory medication, rest and physical therapy or worsening of symptoms during trial of conservative management
A. Symptoms [One of the following]
1. Sudden sharp pain in the upper arm
2. Pop or snap can be heard
3. Cramping of upper arm over the biceps with use of the arm
4. Bruising of the upper arm
5. Pain or tenderness
6. Weakness of the shoulder or elbow on examination
7. Difficulty with pronation and/or supination
8. Bulge in the upper arm
9. Defect over the muscle
XI. Rotator cuff impingement syndrome1,12 or shoulder bursitis with or without an x-ray showing either acromial spur, calcification of the coracoacromial ligament or acromioclavicular arthritis and incomplete resolution with at least 4 weeks of ice, rest, physical therapy and anti-inflammatory medication or steroid injections or symptoms worsening while on conservative management [One of the following]
A. Symptoms
1. Shoulder pain increased by overhead movements
2. Pain interfering with sleep when lying on the affected side
XII. Soft tissue mass including soft tissue sarcoma with negative x-ray (MRI without and with contrast is strongly preferred except for the evaluation of a ganglion [See below] and a lipoma for which CT is preferred) [One of the following]13-17
A. Palpable soft tissue mass not explained by US
B. Prominent calcifications on plain film
C. Follow up of spontaneous bleed into the soft tissues
D. Increasing size of known soft tissue mass
E. Recent trauma, suspected hematoma negative US
F. Suspected ganglion (most common in hand and wrist when they occur in the upper extremity) which fails to respond to aspiration or recurs after aspiration or is solid on transillumination or ultrasound
G. Suspected lipoma must have non diagnostic CT
H. Soft tissue sarcoma of the extremity [One of the following]
1. Initial staging
2. Follow up after surgery to establish a new baseline
3. Post operative imaging after primary therapy for any stage tumor
4. Surveillance for local recurrence in an asymptomatic individual [One of the following]
a. 3-6 months for 5 years
b. Annually years 5-10
5. Suspicion of local recurrence [One of the following]
a. New or recurrent symptoms
b. New or recurrent mass
c. New changes on x-ray or other imaging
XIII. Child abuse
XIV. Soft tissue abscess with negative ultrasound and tender or warm or erythematous area – See MRI without and with contrast, CPT code 73223
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS code 70336:
Covered for:
238.0
|
Neoplasm of uncertain behavior of other and unspecified sites and tissue, bone and articular cartilage
|
524.01–524.06
|
Major anomalies of jaw size
|
524.61–524.63
|
Temporomandibular joint disorders
|
714.0
|
Rheumatoid arthritis
|
714.30
|
Polyarticular juvenile rheumatoid arthritis, chronic or unspecified
|
714.9
|
Unspecified inflammatory polyarthropathy
|
715.18
|
Osteoarthrosis, localized, primary, other specified sites
|
715.28
|
Osteoarthrosis, localized, secondary, other specified sites
|
715.38
|
Osteoarthrosis, localized, not specified whether primary or secondary, other specified sites
|
715.98
|
Osteoarthrosis, unspecified whether generalized or localized, other specified sites
|
716.68
|
Unspecified monoarthritis, other specified sites
|
716.88
|
Other specified arthropathy, of other specified sites
|
716.98
|
Arthropathy, unspecified, of other specified sites
|
718.08
|
Articular cartilage disorder, other specified sites
|
718.98
|
Unspecified derangement of joint, other specified sites
|
719.08
|
Effusion of joint, other specified sites
|
730.08
|
Acute osteomyelitis, other specified sites
|
733.45
|
Aseptic necrosis of bone, jaw
|
784.0*
|
Headache
|
*Note: Use784.0 when the headache is suspected to be caused by temporomandibular joint problems.
| |
784.92
|
Jaw pain
|
848.1
|
Other and ill-defined sprains and strains, jaw
|
Medicare is establishing the following limited coverage for CPT/HCPCS codes 73221, 73222, 73223, 73721, 73722 and 73723:
Covered for:
170.4–170.5
|
Malignant neoplasm of bone and articular cartilage
|
170.7–170.8
|
Malignant neoplasm of bone and articular cartilage
|
171.2–171.3
|
Malignant neoplasm of connective and other soft tissue
|
171.6
|
Malignant neoplasm of connective and other soft tissue, pelvis
|
195.4–195.5
|
Malignant neoplasm of other and ill-defined sites
|
196.3
|
Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb
|
196.5
|
Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb
|
198.5
|
Secondary malignant neoplasm of other specified sites, bone and bone marrow
|
213.3–213.9
|
Benign neoplasm of bone and articular cartilage
|
238.0
|
Neoplasm of uncertain behavior, bone and articular cartilage
|
239.2
|
Neoplasms of unspecified nature, bone, soft tissue, and skin
|
274.00–274.03
|
Gouty arthropathy
|
696.0
|
Psoriatic arthropathy
|
711.01–711.07
|
Arthropathy associated with infection, pyogenic arthritis
|
711.41–711.47
|
Arthropathy associated with other bacterial diseases
|
711.61–711.67
|
Arthropathy associated with mycoses
|
711.91–711.97
|
Arthropathy associated with infection, unspecified infective arthritis
|
713.5
|
Arthropathy associated with neurological disorders
|
Note: Use 713.5 for Charcot’s joints
| |
714.0
|
Rheumatoid arthritis
|
714.30–714.31
|
Juvenile chronic polyarthritis
|
714.9
|
Unspecified inflammatory polyarthropathy
|
715.11–715.17
|
Osteoarthrosis, localized, primary
|
715.21–715.27
|
Osteoarthrosis, localized, secondary
|
715.31–715.37
|
Osteoarthrosis, localized, not specified whether primary or secondary
|
715.89
|
Osteoarthrosis, involving, or with mention of more than one site, but not specified as generalized, multiple sites
|
715.97–715.98
|
Osteoarthrosis, unspecified whether generalized or localized
|
716.11–716.17
|
Traumatic arthropathy
|
716.81–716.89
|
Other specified arthropathy
|
716.91–716.99
|
Arthropathy, unspecified
|
717.0–717.3
|
Internal derangement of knee
|
717.40–717.43
|
Derangement of lateral meniscus
|
717.5–717.7
|
Internal derangement of knee
|
717.81–717.85
|
Other internal derangement of knee
|
717.89
|
Other internal derangement of knee, other
|
718.01–718.05
|
Articular cartilage disorder
|
718.07–718.09
|
Articular cartilage disorder
|
718.11–718.15
|
Loose body in joint
|
718.17–718.19
|
Loose body in joint
|
718.21–718.27
|
Pathological dislocation
|
718.29
|
Pathological dislocation, multiple sites
|
718.31–718.37
|
Recurrent joint dislocation
|
718.39
|
Recurrent joint dislocation, multiple sites
|
718.41–718.47
|
Contracture of joint
|
718.49
|
Contracture of joint, multiple sites
|
718.51–718.57
|
Ankylosis of joint
|
718.59
|
Ankylosis of joint, multiple sites
|
718.77
|
Developmental dislocation of joint, ankle and foot
|
718.98
|
Unspecified derangement of joint, other specified sites
|
719.01–719.07
|
Effusion of joint
|
719.41–719.47
|
Pain in joint
|
719.51–719.57
|
Stiffness of joint, not elsewhere classified
|
719.61–719.67
|
Other symptoms referable to joint
|
719.81–719.87
|
Other specified disorders of joint
|
726.0
|
Adhesive capsulitis of shoulder
|
726.10–726.12
|
Rotator cuff syndrome of shoulder and allied disorders
|
726.19
|
Other specified disorders of shoulder
|
726.2
|
Other affections of shoulder region, not elsewhere classified
|
726.31–726.33
|
Enthesopathy of elbow region
|
726.4–726.5
|
Peripheral enthesopathies and allied syndromes
|
726.60–726.65
|
Enthesopathy of knee
|
726.69
|
Enthesopathy of knee, other
|
726.70–726.73
|
Enthesopathy of ankle and tarsus
|
726.79
|
Enthesopathy of ankle and tarsus, other
|
727.00
|
Synovitis and tenosynovitis, unspecified
|
727.03
|
Synovitis and tenosynovitis, trigger finger (acquired)
|
727.05–727.06
|
Synovitis and tenosynovitis
|
727.41
|
Ganglion and cyst of synovium, ganglion of joint
|
727.51
|
Synovial cyst of popliteal space
|
727.61
|
Complete rupture of rotator cuff
|
727.63–727.64
|
Rupture of tendon, non-traumatic
|
727.66–727.68
|
Rupture of tendon, non-traumatic
|
730.01–730.08
|
Acute osteomyelitis
|
730.11–730.19
|
Chronic osteomyelitis
|
730.21–730.29
|
Unspecified osteomyelitis
|
730.91–730.97
|
Unspecified infection of bone
|
731.0
|
Osteitis deformans without mention of bone tumor
|
731.3
|
Major osseous defects
|
732.1
|
Juvenile osteochondrosis of hip and pelvis
|
732.3–732.5
|
Osteochondropathies
|
732.9
|
Unspecified osteochondropathy
|
733.41–733.44
|
Aseptic necrosis of bone
|
733.49
|
Aseptic necrosis of bone, other
|
831.00–831.04
|
Dislocation of shoulder, closed
|
831.09
|
Dislocation of shoulder, closed, other
|
831.10–831.14
|
Dislocation of shoulder, open
|
831.19
|
Dislocation of shoulder, open, other
|
832.00–832.04
|
Dislocation of elbow, closed
|
832.10–832.14
|
Dislocation of elbow, open
|
833.00–833.05
|
Dislocation of wrist, closed
|
833.09
|
Dislocation of wrist, closed, other
|
833.10–833.15
|
Dislocation of wrist, open
|
833.19
|
Dislocation of wrist, open, other
|
834.00–834.02
|
Dislocation of finger, closed
|
834.10–834.12
|
Dislocation of finger, open
|
835.00–835.03
|
Dislocation of hip, closed
|
835.10–835.13
|
Dislocation of hip, open
|
836.0–836.4
|
Dislocation of knee
|
836.50–836.54
|
Other dislocation of knee, closed
|
836.59
|
Dislocation of knee closed, other
|
836.60–836.64
|
Other dislocation of knee, open
|
836.69
|
Dislocation of knee open, other
|
837.0–837.1
|
Dislocation of ankle
|
840.0
|
Sprains and strains of shoulder and upper arm, acromioclavicular (joint) (ligament)
|
840.3–840.6
|
Sprains and strains of shoulder and upper arm
|
840.8–840.9
|
Sprains and strains of shoulder and upper arm
|
841.0–841.3
|
Sprains and strains of elbow and forearm
|
841.8–841.9
|
Sprains and strains of elbow and forearm
|
842.00–842.02
|
Sprains and strains of wrist
|
842.09
|
Sprains and strains of wrist, other
|
842.11
|
Sprains and strains of hand, carpometacarpal (joint)
|
842.19
|
Sprains and strains of hand, other
|
843.8–843.9
|
Sprains and strains of hip and thigh
|
844.0–844.3
|
Sprains and strains of knee and leg
|
844.8–844.9
|
Sprains and strains of knee and leg
|
845.00–845.03
|
Sprains and strains of ankle
|
845.09
|
Sprains and strains of ankle, other
|
845.10–845.13
|
Sprains and strains of foot
|
845.19
|
Sprains and strains of foot, other
|
848.1
|
Other and ill-defined sprains and strains, jaw
|
848.41–848.42
|
Other and ill-defined sprains and strains, sternum
|
848.5
|
Other and ill-defined sprains and strains, pelvis
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
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, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies. The physician must clearly state the clinical indication/medical necessity for the study in the order for the test.
No comments:
Post a Comment