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? correct CPT for MRI brachial plexus/axilla

  1. #1
    Default ? correct CPT for MRI brachial plexus/axilla
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    Order: MRI OF LEFT AXILLA (BRACHIAL PLEXUS) DX: R/O GROWTH OF LEFT AXILLA W/WO CONTRAST

    Report:

    MRI OF THE LEFT BRACHIAL PLEXUS AND AXILLA WITHOUT AND WITH INTRAVENOUS
    GADOLINIUM:CLINICAL INDICATION: Pain, numbness and tingling left upper extremity and pain in the
    back. There is question of palpable mass within the left axilla.TECHNIQUE: Multiplanar, multisequence MRI of the left axilla and left brachial plexus
    were performed, before and following the intravenous administration of 15 cc of
    gadolinium. IV access was obtained on site. Vitamin E marker was placed on the skin in
    the area of palpable concern as indicated by the patient.FINDINGS: On precontrast images, T2 and T2-weighted images, there is no MR definable
    mass, near area of palpable concern. Of note, there is prominent fat in that location but
    no encapsulation, to suggest the presence of a focal lipoma. There is no visible axillary
    adenopathy. There is no mass, supraclavicular. The brachial plexus, demonstrates normal
    signal intensity and contour. There is no increased signal within the nerves on inversion
    recovery imaging.The glenohumeral alignment is grossly maintained on the left. There is no definite MR
    evidence of acute fracture. The visualized portion of the mediastinum is unremarkable. The visualized thyroid gland is
    grossly unremarkable. Post-gadolinium administration, there is normal enhancement, in the left subclavian vein,
    and left subclavian and axillary arteries. There is no abnormal enhancement, or
    enhancing mass seen.
    IMPRESSION: 1. Normal MR examination of the left brachial plexus and left axilla. No mass is identified.
    Clinical followup is advised. Negative MR examination should not deter biopsy of a clinically suspicious palpable
    finding.

    Insurance approved 73223 and we billed it out as 71552???

    HELP!!!! Is the axilla/brachial plexus really considered a joint?

  2. #2
    Default
    According to the ACR (bulletin, Feb 2001), the chest can be coded when doing a brachial plexus scan to identify apical lung cancers (found CSI Navigator). I have coded brachial plexus scans this way also, but most of the time, they tend to fall under upper extremity non-joint (73218) based on the reporting details. I've never personally coded one as a joint. Hope that helps a little.

  3. #3
    Default
    Other opinions???

    Thanks.

    Kimberley Tober, CPC
    Franklin, TN

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