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Date Printed: June 23, 2017: 11:37 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70540-24

Original Effective Date: 01/01/14

Reviewed: 02/26/15

Revised: 03/15/15

Subject: Magnetic Resonance Cholangiopancreatography (MRCP)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    

DESCRIPTION:

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive magnetic resonance imaging radiologic technique that produces detailed images of the hepatobiliary and pancreatic system, including the liver, gall bladder, bile ducts, pancreas and pancreatic duct.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the magnetic resonance cholangiopancreatography (MRCP) and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Magnetic resonance cholangiopancreatography (MRCP) meets the definition of medical necessity for the following:

BILLING/CODING INFORMATION:

CPT Coding:

S8037

Magnetic resonance cholangiopancreatography (MRCP)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Re-imaging or additional imaging due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for of the magnetic resonance cholangiopancreatography (MRCP).

Documentation Table

LOINC Codes

LOINC

Time Frame

Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the member’s contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American College of Radiology ACR Appropriateness Criteria®: Acute Pancreatitis, 2010.
  2. American College of Radiology ACR Appropriateness Criteria®: Jaundice, 2012.
  3. National Imaging Associates, Inc. MR Cholangiopancreatography (MRCP), 07/14.
  4. Vitellas KM, Keogan MT, Spritzer CE, et al. MR Cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique. RadioGraphics 2000; 20: 939-957.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/26/15.

GUIDELINE UPDATE INFORMATION:

01/01/14

New Medical Coverage Guideline.

01/01/15

Revised indication for suspected congenital anomaly of the pancreaticobiliary tract and complications of chronic pancreatitis. Deleted indications; evaluation of enlarged liver, and complications of congenital anomalous pancreaticobiliary disease. Added indications; pre-operative evaluation prior to surgery or other invasive procedure, post-operative evaluation of suspected biliary abnormalities after surgery or invasive procedure, further evaluation of inconclusive abnormalities identified on other imaging (ultrasound, CT, or MRI), and evaluation of abnormality related to the biliary tree. Updated references.

03/15/15

Annual review; position statement unchanged.

Date Printed: June 23, 2017: 11:37 AM