Radiology Coding Alert

Question: A referring physician ordered an MRI with contrast, but our tech accidentally performed a study without and with contrast. The radiologist read the study as an MRI of the brain, enhanced and unenhanced. What should I report?


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Answer: In this case, you should report 70552 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; with contrast material[s]). Although your providers performed all the services described by 70553 (... without contrast material, followed by contrast material[s] and further sequences), the referring physician did not order this test, which means you can't report it. 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 report 70553 only if the ordering physician specifically asked you to perform the MRI without, then with, contrast. Don't miss: If the tech performed the without and with exam because the radiologist contacted the referring physician to suggest that the without/with exam was medically indicated and the referring physician amended the order to without/with, then you may report 70553. The radiologist's report should include the reason for the changed order. -- The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.