Mri Brachial plexus CPT

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Hi Please let me know the CPT for this scenario ?

MRI BRACHIAL PLEXUS W / W/O CONT

Clinical: Neck and left shoulder blade pain. Previous cervical spine surgery

Technique: Multiplanar multisequence imaging of the left brachial plexus completed
before and after intravenous contrast administration. The patient was taken out
of the scanner due to pain and then resumed the examination requiring new localizer
views. The latter pulse sequences therefore cannot be used to triangulate anatomy
from the first part of the examination. There is some motion artifact toward the
end of the examination.

Findings: Comparison cervical spine MRI and CT examinations 5/22/2016. Stigmata
previous anterior and posterior cervical fusion redemonstrated with some susceptibility
hardware artifact.

T1 hypointense/T2 hyperintense enhancing soft tissue signal abnormality at the thoracic
inlet on the left C7-T1 levels in the region of the C8 and T1 nerve roots of the
brachial plexus. Reactive T2 hyperintense marrow signal changes in the left first
rib (series 7 image 10, series 8 image 22, series 15 image 12) at the costovertebral
junction in the region of the soft tissue. There is spondylosis at C7-T1 and costovertebral
arthrosis at T1, seen best on the cervical spine CT examination. The remaining components
of the brachial plexus are unremarkable. The abnormality is inferior to the level
of spinal surgery.

Impression:
Enhancing soft tissue signal abnormality at the thoracic inlet on the left C7-T1
levels in the region of the C8 and T1 nerve roots of the brachial plexus. Reactive
marrow signal changes of the first rib at the costovertebral junction. Differential
considerations include traumatic, arthritic, inflammatory and neoplastic processes.
Clinical correlation and follow-up examination may be considered.
 

jsalzer50

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modifier -26

72156-26
72157-26

I chose these 2 codes because 72156 states: "Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical"

This supports the Technique section of the report. Also chose these 2 codes because there is extensive mention of C-spine and T-spine findings and impressions.

My gut says to use modifier -26 for the professional component, as it seems a physician usually orders the MRI, and then the MRI is read and interpreted by the Radiologist (outside the office, but sometimes in-house), and then the Radiologist dictates the MRI report to be sent back to the attending physician.

Hope this helps! I would greatly appreciate other points of view and what others have to say about this too.

Sincerely,
Jacob
 
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