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Billing and Coding: MRI and CT Scans of the Head and Neck (A57204)

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Billing and Coding: MRI and CT Scans of the Head and Neck (A57204) FUTURE Local Coverage Article: Billing and Coding: MRI and CT Scans of the Head and Neck (A57204) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information CONTRACTOR NAME CONTRACT TYPE CONTRACT JURISDICTION STATE(S) NUMBER Noridian Healthcare Solutions, A and B MAC 01111 - MAC A J - E California - Entire State LLC Noridian Healthcare Solutions, A and B MAC 01112 - MAC B J - E California - Northern LLC Noridian Healthcare Solutions, A and B MAC 01182 - MAC B J - E California - Southern LLC Noridian Healthcare Solutions, A and B MAC 01211 - MAC A J - E American Samoa LLC Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, A and B MAC 01212 - MAC B J - E American Samoa LLC Guam Hawaii Northern Mariana Islands Noridian Healthcare Solutions, A and B MAC 01311 - MAC A J - E Nevada LLC Noridian Healthcare Solutions, A and B MAC 01312 - MAC B J - E Nevada LLC Noridian Healthcare Solutions, A and B MAC 01911 - MAC A J - E American Samoa LLC California - Entire State Guam Hawaii Nevada Northern Mariana Created on 09/17/2020. Page 1 of 237 CONTRACTOR NAME CONTRACT TYPE CONTRACT JURISDICTION STATE(S) NUMBER Islands Article Information General Information Article ID Original Effective Date A57204 10/01/2019 Article Title Revision Effective Date Billing and Coding: MRI and CT Scans of the Head and 10/01/2020 Neck Revision Ending Date Article Type N/A Billing and Coding Retirement Date AMA CPT / ADA CDT / AHA NUBC Copyright N/A Statement CPT codes, descriptions and other data only are copyright 2019 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Current Dental Terminology © 2019 American Dental Association. All rights reserved. Copyright © 2020, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial Created on 09/17/2020. Page 2 of 237 use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312) 893-6814. You may also contact us at [email protected]. CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary. Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim, which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits Medicare payment for services and items that are experimental or investigational. CMS publication 100-3, Medicare National Coverage Determinations, Sections 220.1 “Computerized Tomography”, and 220.2-220.2.B.2d and Section 220.2.C-220.2.D “Magnetic Resonance Imaging”. Denies coverage of MRI for: 1. Imaging of cortical bone and calcification; 2. Procedures involving spatial resolution of bone or calcification; 3. MRI is not covered for patients with metallic clips on vascular aneurysms CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40. Denies coverage of MRI for: 1. Measurement of blood flow and spectroscopy Article Guidance Article Text: The following coding and billing guidance is to be used with its associated Local Coverage Determination. Documentation Guidelines Diagnostic evaluation of the head and neck (head/neck scans) performed by computerized tomography (CT) scanners is covered when the documentation supports that the scan is reasonable and necessary. Accurate coding information must be provided with claims to differentiate CT and/or MRI scans from other radiology services and to Created on 09/17/2020. Page 3 of 237 make coverage determinations. Sufficient documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the medical records. This information must be available to Medicare upon request. Coding Guidelines The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits in addition to guidance in this LCD. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Whichever guidance is more restrictive should be adhered to. Coding Information CPT/HCPCS Codes Group 1 Paragraph: CT Scans Group 1 Codes: CODE DESCRIPTION 70450 Ct head/brain w/o dye 70460 Ct head/brain w/dye 70470 Ct head/brain w/o & w/dye 70480 Ct orbit/ear/fossa w/o dye 70481 Ct orbit/ear/fossa w/dye 70482 Ct orbit/ear/fossa w/o&w/dye 70486 Ct maxillofacial w/o dye 70487 Ct maxillofacial w/dye 70488 Ct maxillofacial w/o & w/dye 70490 Ct soft tissue neck w/o dye 70491 Ct soft tissue neck w/dye 70492 Ct sft tsue nck w/o & w/dye 72125 Ct neck spine w/o dye 72126 Ct neck spine w/dye 72127 Ct neck spine w/o & w/dye Created on 09/17/2020. Page 4 of 237 Group 2 Paragraph: MRI Scans Group 2 Codes: CODE DESCRIPTION 70336 Magnetic image jaw joint 70540 Mri orbit/face/neck w/o dye 70542 Mri orbit/face/neck w/dye 70543 Mri orbt/fac/nck w/o &w/dye 70551 Mri brain stem w/o dye 70552 Mri brain stem w/dye 70553 Mri brain stem w/o & w/dye 70557 Mri brain w/o dye 70558 Mri brain w/dye 70559 Mri brain w/o & w/dye 72141 Mri neck spine w/o dye 72142 Mri neck spine w/dye 72156 Mri neck spine w/o & w/dye CPT/HCPCS Modifiers N/A ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The following list of ICD-10-CM codes represents diagnoses that, alone or together, support the medical necessity of either MRIs or CTs. These diagnoses must be supported by appropriate documentation of medical necessity in the medical record. These are the only covered diagnoses: Group 1 Codes: ICD-10 CODE DESCRIPTION A02.21 Salmonella meningitis A06.6 Amebic brain abscess A17.0 Tuberculous meningitis A17.1 Meningeal tuberculoma Created on 09/17/2020. Page 5 of 237 ICD-10 CODE DESCRIPTION A17.81* Tuberculoma of brain and spinal cord A17.82* Tuberculous meningoencephalitis A17.83* Tuberculous neuritis A17.89* Other tuberculosis of nervous system A18.01 Tuberculosis of spine A18.03* Tuberculosis of other bones A18.51 Tuberculous episcleritis A18.52 Tuberculous keratitis A18.53 Tuberculous chorioretinitis A18.54 Tuberculous iridocyclitis A18.59 Other tuberculosis of eye A18.6 Tuberculosis of (inner) (middle) ear A27.81 Aseptic meningitis in leptospirosis A32.11 Listerial meningitis A32.12 Listerial meningoencephalitis A32.7 Listerial sepsis A32.81 Oculoglandular listeriosis A32.89* Other forms of listeriosis A39.0 Meningococcal meningitis A39.1 Waterhouse-Friderichsen syndrome A39.2 Acute meningococcemia A39.3 Chronic meningococcemia A39.81 Meningococcal encephalitis A39.82 Meningococcal retrobulbar neuritis A39.83* Meningococcal arthritis A39.84* Postmeningococcal arthritis A39.89 Other meningococcal infections A41.9 Sepsis, unspecified organism A50.32 Late congenital syphilitic chorioretinitis A50.39 Other late congenital syphilitic oculopathy A50.40 Late congenital neurosyphilis, unspecified A50.41 Late congenital syphilitic meningitis Created on 09/17/2020. Page 6 of 237 ICD-10 CODE DESCRIPTION A50.42 Late congenital syphilitic encephalitis A50.43 Late congenital syphilitic polyneuropathy A50.44 Late congenital syphilitic optic nerve atrophy A50.45 Juvenile general paresis A50.49 Other late congenital neurosyphilis A50.59 Other late congenital syphilis, symptomatic A51.41 Secondary syphilitic meningitis A52.11 Tabes dorsalis A52.12 Other cerebrospinal syphilis A52.13 Late syphilitic meningitis A52.14 Late syphilitic encephalitis A52.15 Late syphilitic neuropathy A52.19 Other symptomatic neurosyphilis A54.81 Gonococcal meningitis A80.0 Acute paralytic poliomyelitis, vaccine-associated A80.1 Acute paralytic poliomyelitis, wild virus, imported A80.2 Acute paralytic poliomyelitis, wild virus, indigenous A80.39 Other acute paralytic poliomyelitis A80.4 Acute nonparalytic poliomyelitis A81.00 Creutzfeldt-Jakob disease, unspecified A81.01 Variant Creutzfeldt-Jakob disease A81.09 Other Creutzfeldt-Jakob disease A81.1 Subacute sclerosing panencephalitis A81.2 Progressive multifocal leukoencephalopathy A81.81 Kuru A81.82 Gerstmann-Straussler-Scheinker syndrome A81.83 Fatal familial insomnia A81.89 Other atypical virus infections of central nervous system A81.9 Atypical virus infection of central nervous system, unspecified A82.0 Sylvatic rabies A82.1 Urban rabies A83.0 Japanese encephalitis Created on 09/17/2020. Page 7 of 237 ICD-10 CODE
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