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This blog outlines CPT coding for head MRI’s including key codes, differences with contrast, modifiers, documentation, medical necessity, and modifiers. It also discusses billing mistakes, prior auth with payers, bundling, and compliance. Healthcare providers can follow best practices in coding and documentation to decrease denials, optimize reimbursement, and keep MRI billing processes audits with accurate coding.
An MRI of the head aids in the assessment of neurological diseases and injuries, brain tumors, infections, and vascular malformations. These services are invaluable but are also expensive, and therefore subject to strict coding, documentation, and compliance reviews. Correct CPT code usage will guarantee the organization gets reimbursed, claim denials are kept to a minimum, and the procedure is justified medically. This blog focuses on head MRI CPT coding, including head MRI CPT coding options, use of modifiers, documentation, expectations by payers, compliance, and the coding and billing processes.
What Is An MRI of the Head?
An MRI of the head uses strong magnetic fields and radio waves to create images of the brain, the bottom of the skull, and the structures around it. Head CT scans are also used in the imaging of the head, but MRI is preferred as it uses no ionizing radiation and has a better contrast resolution for soft tissue. Physicians examine head MRI results for signs of stroke, tumors, seizures, severe headaches or other neurological problems, and for changes of vision or mental state. There are numerous reasons for ordering and assisting in the completion of an MRI head exam, thus it is important to ensure the organization uses the correct CPT.
Main CPT Codes for MRI of the Head
Different MRI studies of the brain and head are described by various CPT codes depending on the application of contrast. CPT code 70551 applies to MRI of the brain. CPT code 70552 applies to MRI of the brain with contrast material, and CPT code 70553 applies to MRI of the brain whether or not contrast is used. These three codes are most common for head MRI services. It’s worth noting that CPT codes specify the difference between brain MRI and other head imaging, such as orbits, face, or neck MRI. Selecting the most appropriate code requires careful analysis of the physician order and the radiology report to ascertain the anatomical region that was interrogated, as well as the presence or absence of contrast.
Variations Between With and Without Contrast Studies
Some blood vessels and types of tumors and inflammation may not be present on some of the initial imaging, but may be seen on follow-up imaging after contrast is administered due to the breakdown of the blood-brain barrier and the introduction of the contrast material. Documentation for the Head MRI must include the type of contrast administered and the clinical reason for administering the contrast. If in the same session, both non- contrast and contrast-enhanced images are obtained, report CPT 70553 and do not bill for different codes. Reporting multiple MRI codes for the same area of anatomy incorrectly is audited and denied.
Professional and Technical Components
Imaging MRI services have two parts: the professional part and the technical part. Technical parts relate to the equipment and supplies, and the work of the technologist, and professional parts relate to the interpretation and the report by the radiologist. Providers in in-office imaging centers can bill the global service. Out in the hospital settings, facilities in general bill the technical part, and the radiologists do the billing for the professional part, using modifier 26. Knowing about splits helps to get the billing right and to ensure the payment is right.
Standard Head MRI Modifiers
Modifiers are integral to MRI service line item billing, particularly when services are split, reduced, or repeated. For example, modifier 26 is billed to represent the professional component exclusively. Modifier TC is the technical component billed separately. Modifier 59 or one of the specific X modifiers is acceptable when separate MRI services are provided in addition to another imaging procedure on the same date, provided that unbundled service conditions apply.
When the same provider does a repeat MRI of the head on the same day, modifier 76 is applicable. For the same case, modifier 77 applies when the repeat study is performed by a different provider. Modifier 52 is applicable when the study is reduced or stopped, and the documentation must justify why the full study was not completed.
Medical Necessity Requirements
Most MRI reimbursement claims are denied when the medical necessity of the MRI is questioned by the payers. Medical necessity is questioned when the diagnosis codes are not aligned with the MRI reimbursement claims. There need to be conclusive symptoms like severe headache, seizure activity, suspected stroke, or known neurological disease, and they need to be documented.
The ordering physician’s notes ought to detail the patient’s condition, what treatments or imaging were performed in the past, and what the MRI is supposed to resolve. One would need to ensure that the OCR diagnosis code is in line with the CPT MRI code. If the CPT MRI code combination spells out a medically appropriate study, vague or nonspecific diagnosis codes would lead to denial of reimbursement from the payers.
Documentation Standards
Thorough and complete documentation is paramount to be compliant. Documentation must include the physician order, the medical study justification, pertinent history of the patient, and the necessary findings from the physical exam that are relevant to the study. The radiology report must be cognizant of which MRI study was performed, if contrast was used or not, which body part or zone was imaged, and what findings were present. If contrast was used, the report must be cognizant of what type and the quantity of the contrast agent that was used and a note on the patient’s tolerance of the contrast. In order to justify the code that has been billed and also justify the medical necessity in the process of an audit, succinct documentation is needed.
Bundling and Unbundling Issues
The head MRI is subject to the National Correct Coding Initiative (NCCI) edits, as do many other facets of health care billing. These edits do state which codes can be billed together or not billed together, as in for example, overlapped anatomy. If a coding for an MRI for overlapped anatomy is billed, it will not be billed appropriately without an appropriate modifier. Compliance in the awareness of coding under which billing falls provides a framework under which the provider is protected from improper coding and the risk of being audited.
Common Billing Errors
Errors include selecting the wrong MRI code, billing separate codes when they should be merged together, not adding the required modifier, not adding a modifier when it is required, and billing with unsupported diagnosis codes. In other cases, documentation is lacking, and in some cases, there is no medical justification. These problems can be addressed within the organizational structures and processes prior to submitting a claim to an insurance provider by focusing on improved staff education and enhanced audits.
Compliance and Audit Readiness
Having MRI services done is expensive, therefore they are audits. Having clear policies on MRI services, including coding, modifiers, and documentation is vital. Regular internal audits can reveal some error trends and where improvements can be made. Radiologist and referring physicians standard reporting and documentation must be done is also a part of compliance. The clinical and billing teams working together improves compliance.
Reimbursement Considerations
There are many variables for reimbursement of head MRI services, such as the payer, location, and service details. Each of the Medicare, Medicaid, and private insurers will have different policies and fee schedules along with them.
Having knowledge of what is owed to the practice for services is important for the practice to detect if payments are less than they should be and to file appeals. Having the services coded correctly, the right modifiers applied, and completed documentation all have a direct impact on the ability to get paid for the service.
Best Practices for Accurate MRI Coding
Some of the best practices include verifying the physician services ordered, determining if contrast was used, checking if the radiology report was accurate, confirming with office payer policies, and all of this must be done prior to submitting a claim.
Educating coders and billers at regular intervals is important to maintain knowledge with the latest payer policies and CPT guidelines. The use of claim-editing software along with coding software will reduce the number of mistakes made and make it easier to get claims accepted on the first try.
Conclusion
MRI head coding requires understanding the CPT code structure, how to apply modifiers, the rules of the documentation, and the policies of the payer. Adhering to guidance, establishing medical necessity, and maintaining robust compliance minimizes the risk of denial, increases reimbursement, and lowers the risk of an audit. MRI coding is essential for ensuring financial sustainability and providing effective care.
Make An Appintment With A2ZFAQs
Depending on how the study is conducted, the most frequent codes are 70551 (no contrast), 70552 (with contrast), and 70553 (with and without contrast).
Modifier 26 is applicable when only the technical component of the MRI is being billed.
When both are done on the same day, it is not appropriate. One should file CPT 70553.
The reason for the medical necessity must be contained in the diagnosis codes, or the claim will be denied.
Insurers often want prior authorization, so it is necessary to check the policies of the payers prior to scheduling.