Radiology Coding Alert

Question: A neurosurgeon referred a patient to our independent diagnostic testing facility for an MRI of the brain with contrast enhancement. Our technologist accidentally performed the study without and with contrast, and our radiologist read the study as an MRI of the brain, enhanced and unenhanced. Should we report 70552 or 70553?

Kansas Subscriber
 
Answer: Because the referring physician ordered a brain MRI "with contrast enhancement," you should report 70552 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; with contrast material[s]).

Your practice will most likely have to write off the cost of your MRI without contrast, because the referring physician did not order it. You should only report 70553 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material, followed by contrast material[s] and further sequences) if the ordering physician specifically asked you to perform the MRI without, then with, contrast.

But if the study you performed was medically indicated (and the study that the physician ordered was not medically indicated), you may have an alternative. The radiologist should contact the referring physician and discuss the case and the correct imaging algorithm.

If the referring physician agrees that the study should be changed from the study originally ordered to the correct type of study, the referring physician should supply an amended order, and the radiologist's interpretation should include the reasons for the changed order. In this circumstance, you should report 70553.