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Date Printed: October 23, 2017: 07:21 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.

04-70540-15

Original Effective Date: 07/01/07

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Magnetic Resonance Imaging (MRI) Upper 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 Update    
           

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:

Indications for upper extremity MRI (hand, wrist, arm, elbow or shoulder) (plain radiographs must precede MRI evaluation):

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 known or suspected 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 an upper extremity (hand, wrist, arm, elbow, or shoulder) MRI:

Additional indications for shoulder MRI:

Additional indications for wrist MRI:

BILLING/CODING INFORMATION:

CPT Coding:

73218

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

73219

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

73220

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

73221

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

73222

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

73223

Magnetic resonance (e.g., proton) imaging, any joint of upper 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 (73218-73223) performed on the same anatomical area is limited to one (1) MRI imaging within a 6-month period. MRI imaging (73218-73223) 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 (73218-73223) 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 (73218-73223) within a 12-month period. MRI imaging (73218-73223) 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) upper 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 BCBSF 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 the Upper Extremity, (L29223) 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:

Aseptic necrosis: increasing sclerosis and cystic changes in the head of the femur, which sometimes follow traumatic dislocation of the hip. A similar condition sometimes develops in the head of the humerus after shoulder dislocation.

Osteomyelitis: inflammation of bone caused by infection, usually by a pyogenic organism, although any infectious agent may be involved. It may remain localized or may spread through the bone to involve the marrow, cortex, cancellous tissue, and periosteum.

Septic arthritis: infectious arthritis, usually acute, characterized by inflammation of synovial membranes with purulent effusion into a joint or joints, most often due to Staphylococcus aureus. Streptococcus pyogenes, S. pneumoniae, or Neisseria gonorrhoeae, usually caused by hematogenous spread from a primary site of infection although joints may also become infected by direct inoculation or local extension. Also called bacterial, pyogenic, or suppurative arthritis.

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) Lower Extremity, 04-70540-16

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 Bone, Joint, and Soft Tissue Infections in the Extremities, 2014.
  2. ACR-SPR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Elbow, 2014.
  3. ACR-SSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Shoulder, 2014.
  4. ACR–SCBT-MR-SPR-SSR Practice Parameter for the Performance of Magnetic Resonance Imaging (MRI) of the Wrist, 2014.
  5. Blue Cross Blue Association Positional Resonance Imaging (MRI) Medical Policy (6.01.48), 04/14.
  6. Centers for Medicare & Medicaid Services NCD for Magnetic Resonance Imaging (220.2), 06/03/10.
  7. First Coast Service Options, Inc. Local Coverage Determination for Magnetic Resonance Imaging of Upper Extremity (L29223), 10/01/11.
  8. National Imaging Associates, Inc. Clinical Guideline MRI Upper Extremity (hand, wrist, arm, elbow, shoulder) (joint and other than joint) Clinical Guideline, 02/12.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/04/15.

GUIDELINE UPDATE INFORMATION:

07/01/07

New Medical Coverage Guideline.

01/21/08

Updated the Program Exceptions.

07/15/08

Scheduled review. No change in position statement. 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.

10/15/10

Revision related 2010 ICD-9 code added; added 237.73, 237.79, and 447.70 – 447.73 for 73218, 73219, 73220, 73221, 73222, and 73223 to Medicare Advantage products program exception.

10/01/11

Revision; formatting changes.

11/15/12

Annual review; Added indications for the following: evaluation of suspicious mass/tumor, evaluation of known cancer, evaluation of known or suspected infection or inflammatory disease, evaluation of suspected avascular necrosis, evaluation of suspected or known auto immune disease, evaluation of known or suspected fracture and/or injury, evaluation of persistent pain and initial imaging (e.g., x-ray) has been performed, post-operative/procedural evaluation and other indications for an upper extremity MRI (hand, wrist, arm, elbow, or shoulder). Added criteria for imaging which exceed limit. Added statement for re-imaging or additional imaging. Added Medicare Advantage program exception (nationally non-covered indications); MRI of cortical bone and calcifications and procedures involving spatial resolution of bone and calcifications. Deleted Medicare Advantage products ICD-9 codes. Updated references.

01/01/14

Review/revision. Updated program exception.

01/15/15

Scheduled review; added pre-operative/pre-procedural evaluation. Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

Date Printed: October 23, 2017: 07:21 AM