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Date Printed: December 18, 2017: 03:30 PM

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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.

04-70540-16

Original Effective Date: 07/01/07

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Magnetic Resonance Imaging (MRI) Lower Extremity

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    
           

DESCRIPTION:

Magnetic resonance imaging (MRI) is a radiation-free, noninvasive, technique used to produce high quality sectional images of the inside of the body in multiple planes. MRI uses natural magnetic properties of the hydrogen atoms in the body that emit radiofrequency signals when exposed to radio waves within a strong magnetic field. These signals are processed and converted by a computer into high-resolution, three-dimensional, tomographic images. Images and resolution produced by MRI is quite detailed. For some MRI, contrast materials (e.g., gadolinium, gadoteridol, non-ionic and low osmolar contrast media, ionic and high osmolar contrast media) are used to enable visualization of a body system or body structure.

The U.S. Food and Drug Administration’s (FDA) cleared MRI systems for marketing through the 510(k) process. The Fonar Stand-Up MRI system received FDA marketing clearance in October 2000.

POSITION STATEMENT:

MRI of the lower extremity (foot, ankle, knee, leg, hip) meets the definition of medical necessity for the following:

INDICATIONS FOR LOWER EXTREMITY MRI (FOOT, ANKLE, KNEE, LEG or HIP):

Evaluation of suspicious mass/tumor (unconfirmed cancer diagnosis):

Evaluation of known cancer:

For evaluation of known or suspected infection or inflammatory disease (e.g., osteomyelitis):

For evaluation of suspected avascular necrosis (AVN) (e.g., aseptic necrosis, Legg-Calve-Perthes disease in children):

For evaluation of suspected or known Auto Immune Disease (e.g., Rheumatoid arthritis):

For evaluation of known or suspected fracture and/or injury:

For evaluation of persistent pain and initial imaging (e.g. x-ray) has been performed:

Pre-operative/pre-procedural evaluation

Post-operative/procedural evaluation:

Other indications for a Lower Extremity (Foot, Ankle, Knee, Leg or Hip) MRI:

Additional indication specific for FOOT or ANKLE MRI

Additional indications specific for KNEE MRI:

Additional indications specific for HIP MRI:

BILLING/CODING INFORMATION:

CPT Coding:

73718

Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s)

73719

Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; with contrast material(s)

73720

Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73721

Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material

73722

Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; with contrast material(s)

73723

Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

HCPCS Coding:

S8042

Magnetic resonance imaging (MRI), low-field

REIMBURSEMENT INFORMATION:

Reimbursement for MRI imaging (73718-73723) performed on the same anatomical area is limited to one (1) MRI imaging within a 6-month period. MRI imaging (73718-73723) in excess of one (1) within a 6-month period is subject to medical review for medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

Reimbursement for MRI imaging (73718-73723) for an oncologic condition undergoing active treatment or active treatment completed within the previous 12 months on the same anatomical area is limited to four (4) MRI imaging (73718-73723) within a 12-month period. MRI imaging (73718-73723) for an oncologic condition in excess of four (4) within a 12-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

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

Open MRI Units (Stand-Up MRI/Sitting MRI-Positional MRI)

Open MRI units of any configuration, including MRI units that allow imaging when standing (Stand-up MRI) or when sitting (Sitting MRI), are considered to be an acceptable standard alternative to standard “closed” MRI units. Stand-up MRI and sitting MRI may be reported like a standard MRI. No additional payment will be made for stand-up MRI or sitting MRI.

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 magnetic resonance imaging (MRI) lower extremity.

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 Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

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

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging of Lower Extremity, (L29219) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Magnetic Resonance Imaging, (220.2) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Magnetic Resonance Spectroscopy (MRS), 04-70540-07
Magnetic Resonance Imaging (MRI) of the Breast, 04-70540-09

Magnetic Resonance Imaging (MRI) Brain and Head, 04-70540-11

Magnetic Resonance Imaging (MRI) Orbit, Face, Temporomandibular Joint (TMJ) and Neck, 04-70540-12

Magnetic Resonance Imaging (MRI) Chest & Cardiac, 04-70540-13

Magnetic Resonance Imaging (MRI) Abdomen and Pelvis, 04-70540-14

Magnetic Resonance Imaging (MRI) Upper Extremity, 04-70540-15

Magnetic Resonance Imaging (MRI) Spine (Cervical, Thoracic, Lumbar), 04-70540-17

OTHER:

Other names used to report MRI:

Nuclear Magnetic Resonance (NMR)
Open MRI

Other names used to report Positional MRI:

Position MRI (pMRI)
Sitting MRI
Stand-Up MRI
Standing MRI
Weight-bearing MRI

REFERENCES:

  1. ACR–SPR-SSR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Ankle, 2014.
  2. ACR–SPR-SSR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone and Soft Tissue Tumors, 2014.
  3. ACR–SPR-SSR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone, Joint, and Soft Tissue Infections in the Extremities, 2014.
  4. ACR–SPR-SSR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Hip and Pelvis for Musculoskeletal Disorders, 2014.
  5. ACR–SSR Practice Parameter for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Knee, 2014.
  6. ACR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Knee, 2014.
  7. Blue Cross Blue Association Positional Resonance Imaging (MRI) Medical Policy (6.01.48), 04/14.
  8. Centers for Medicare & Medicaid Services NCD for Magnetic Resonance Imaging (220.2), 06/03/10.
  9. First Coast Service Options, Inc. Local Coverage Determination for Magnetic Resonance Imaging of Lower Extremity (L29219), 07/07/11.
  10. National Imaging Associates, Inc. Clinical Guideline Lower Extremity(ankle, foot, knee, hip, leg) (joint and other than joint), 08/13.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/04/14.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/21/08

Updated the Program Exceptions.

07/15/08

Scheduled reviewed. No change in position statement. Revised hip and knee indications; for hip, revise fracture indication (deleted “occult”); for knee, deleted “severe” and add “trauma”. Updated references and related Internet links.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

01/01/10

Revised BCBSF Radiology Management program exception section.

07/15/10

Annual review: format changes, added indications for bone marrow MRI, added program exception for Medicare Advantage products, and updated references.

10/01/11

Revision; formatting changes.

12/15/12

Annual review; added indications for lower extremity MRI (foot, ankle, knee, leg, hip). Added criteria for imaging which exceed limit and statement for re-imaging or additional imaging. Deleted Medicare Advantage products ICD-9 codes. Added Medicare Advantage program exception (nationally non-covered indications) for MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications. Updated references.

01/01/14

Review/revision. Updated program exception.

01/01/15

Scheduled review; deleted “when ordered by surgeon/specialist or a primary care provider on behalf of the surgeon/specialist” from pre-operative and post-operative procedural evaluation and indications for bone marrow MRI (included in Magnetic Resonance Imaging Bone Marrow guideline). Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

Date Printed: December 18, 2017: 03:30 PM