LCD/NCD Portal

L28903 MAGNETIC RESONANCE ANGIOGRAPHY (MRA)

 

 

10/01/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Although MRA appears to be a rapidly developing technology, the clinical safety and effectiveness of this procedure for all anatomical regions has NOT been proven.

• As a result Medicare will provide coverage on a limited basis.

o Below are the indications for which Medicare coverage is allowed for MRA.

o All other uses of MRA will not be covered.

Indications

• Head and Neck (procedure codes 70544-70549)

o ALL of the following criteria must apply in order for Medicare to provide coverage for MRA of the head and neck:

 to evaluate the carotid arteries, the circle of Willis, the anterior, middle or posterior cerebral arteries, the vertebral or basilar arteries or the venous sinuses.

 to verify the need for anticipated surgery for conditions that include, but are not limited to, tumor, aneurysms, vascular malformations, vascular occlusion, or thrombosis.

 Within this broad category of disorders, medical necessity is the underlying determinant of the need for an MRA.

 Because MRA and CA perform the same diagnostic function, the medical records should clearly justify and demonstrate the existence of medical necessity.

 MRA and contrast angiography (CA) are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy.

• Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.

• Chest (procedure code 71555, C8909, C8910, C8911)

o Diagnosis of Pulmonary Embolism.

 Patients who are allergic to iodinated contrast material face a high risk of developing complications if they undergo pulmonary angiography or computed tomography angiography.

 Therefore, Medicare will cover MRA of the chest for diagnosing a suspected pulmonary embolism only when it is contraindicated for the patient to receive intravascular iodinated contrast material.

o Evaluation of Thoracic Aortic Dissection and Aneurysm.

 Medicare will provide coverage only for MRA or for CA when used as a diagnostic test.

 However, if both MRA and CA of the chest are used, the physician must demonstrate the medical need for performing these tests.

 While the intent of this policy is to provide reimbursement for either MRA or CA, CMS is also allowing flexibility for physicians to make appropriate decisions concerning the use of these tests based on the needs of individual patients.

• Peripheral Arteries of Lower Extremities (procedure code 73725, C8912, C8913, C8914)

o Studies have proven that MRA of peripheral arteries is useful in determining the presence and extent of peripheral vascular disease in lower extremities.

o This procedure is non-invasive and has been shown to find occult vessels in some patients for which those vessels were not apparent when CA was performed.

o Medicare will cover either MRA or CA to evaluate peripheral arteries of the lower extremities.

o  However, both MRA and CA may be useful is some cases, such as:

 A patient has had CA and this test was unable to identify a viable run-off vessel for bypass.

 When exploratory surgery is not believed to be a reasonable medical course of action for this patient, MRA may be performed to identify the viable runoff vessel.

 A patient has had MRA, but the results are inconclusive.

• Abdomen (procedure codes 74185, C8900, C8901, C8902) and Pelvis (procedure codes 72198, C8918, C8919, C8920)

o Pre-operative Evaluation of Patients Undergoing Elective Abdominal Aortic Aneurysm (AAA) Repair (Effective July 1, 1999).

 The MRA is covered for pre-operative evaluation of patients undergoing elective AAA repair if the scientific evidence reveals MRA is considered comparable to CA in determining the extent of AAA, as well as in evaluating aortoiliac occlusion disease and renal artery pathology that may be necessary in the surgical planning of AAA repair.

 These studies also reveal that MRA could provide a net benefit to the patient.

 If preoperative CA is avoided, then patients are not exposed to the risks associated with invasive procedures, contrast media, end-organ damage, or arterial injury.

o Imaging the Renal Arteries and the Aortoiliac Arteries in the Absence of AAA or Aortic Dissection.(Effective July 1, 2003).

• The MRA coverage is expanded to include imaging the renal arteries and the aortoiliac arteries in the absence of AAA or aortic dissection.

o MRA should be obtained in those circumstances in which using MRA is expected to avoid obtaining CA, when physician history, physical examination, and standard assessment tools provide insufficient information for patient management, and obtaining an MRA has a high probability of positively affecting patient management.

o However, CA may be ordered after obtaining the results of an MRA in those rare instances where medical necessity is demonstrated.

• Studies show that diagnostic evaluation of several upper abdominal malignancies may require an evaluation for vascular invasion by the tumor in deciding if the patient is a candidate for surgical resection of the tumor.

o One example is with pancreatic carcinoma. Pancreatic head carcinomas can grow in close proximity to the superior mesenteric vein.

• Evidence suggests that MRA provides reliable, noninvasive evaluation of the portal and hepatic veins.

o MRA can provide focused evaluation of particular areas of interest as well as a broad overview anatomic display that is helpful to surgeons and interventionalists planning procedures.

Limitations

• The following MRA services are NOT considered medically reasonable and necessary:

o MRA of the spinal canal and contents.

o MRA of the upper extremities.

 

 

Coding Information

 

Bill Type Codes

 

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

71x Clinic - Rural Health

77x Clinic - Federally Qualified Health Center (FQHC)

85x Critical Access Hospital

 

 

Revenue Codes

 

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0320 Radiology - Diagnostic - General Classification

0321 Radiology - Diagnostic - Angiocardiology

0322 Radiology - Diagnostic - Arthrography

0323 Radiology - Diagnostic - Arteriography

0324 Radiology - Diagnostic - Chest X-Ray

0329 Radiology - Diagnostic - Other Radiology - Diagnostic

0520 Free-Standing Clinic - General Classification

0521 Free-Standing Clinic - Clinic Visit by Member to RHC/FQHC

0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck

0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities

0618 Magnetic Resonance Technology (MRT) - MRA - Other

 

 

CPT/HCPCS Codes

 

CPT/HCPCS Codes that Support Medical Necessity:

 

70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S)

70545 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S)

70546 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

70547 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S)

70548 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S)

70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

71555 MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S)

73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S)

74185 MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S)

72198 MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S)

 

 

For Ambulatory Surgical Centers (ASCs) only:

 

For procedure code 71555 Magnetic resonance angiography, chest(excluding myocardium), with or without contrast material(s) use codes:

 

C8909 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

C8910 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

C8911 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)

 

For procedure code 72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) use codes:

 

C8918 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS

C8919 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS

C8920 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, PELVIS

 

For procedure code 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) use codes:

 

C8912 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY

C8913 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY

C8914 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, LOWER EXTREMITY

 

For procedure code 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) use codes:

 

C8900 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN

C8901 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN

C8902 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, ABDOMEN

 

CPT/HCPCS Codes that DO NOT Support Medical Necessity:

 

72159 MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT CONTRAST MATERIAL(S)

73225 MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S)

 

CPT/HCPCS Codes that DO NOT Support Medical Necessity:

 

For Ambulatory Surgical Centers (ASCs) only:

 

C8931 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8932 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS

C8933 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, SPINAL CANAL AND CONTENTS

C8934 MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY

C8935 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY

C8936 MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, UPPER EXTREMITY

 

 

ICD-9 Codes that Support Medical Necessity

 

MRA of head and neck ( procedure codes 70544-70549):

 

094.89 OTHER SPECIFIED NEUROSYPHILIS

191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE

191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE

191.5 MALIGNANT NEOPLASM OF VENTRICLES

191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS

191.7 MALIGNANT NEOPLASM OF BRAIN STEM

191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN

191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

194.5 MALIGNANT NEOPLASM OF CAROTID BODY

227.5 BENIGN NEOPLASM OF CAROTID BODY

228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES

239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN

325 PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES

430 SUBARACHNOID HEMORRHAGE

431 INTRACEREBRAL HEMORRHAGE

432.1 SUBDURAL HEMORRHAGE

432.9 UNSPECIFIED INTRACRANIAL HEMORRHAGE

433.00 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION

433.01 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION

433.10 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION

433.11 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION

433.20 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL INFARCTION

433.21 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION

433.30 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION

433.31 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION

433.80 OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION

433.81 OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION

433.90 OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION

433.91 OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION

434.00 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION

434.01 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION

434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION

434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION

434.90 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION

434.91 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION

435.0 BASILAR ARTERY SYNDROME

435.1 VERTEBRAL ARTERY SYNDROME

435.2 SUBCLAVIAN STEAL SYNDROME

435.3 VERTEBROBASILAR ARTERY SYNDROME

435.8 OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS

435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

437.3 CEREBRAL ANEURYSM NONRUPTURED

437.4 CEREBRAL ARTERITIS

437.6 NONPYOGENIC THROMBOSIS OF INTRACRANIAL VENOUS SINUS

442.81 ANEURYSM OF ARTERY OF NECK

446.5 GIANT CELL ARTERITIS

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

900.00 INJURY TO CAROTID ARTERY UNSPECIFIED

900.01 INJURY TO COMMON CAROTID ARTERY

900.02 INJURY TO EXTERNAL CAROTID ARTERY

900.03 INJURY TO INTERNAL CAROTID ARTERY

900.1 INJURY TO INTERNAL JUGULAR VEIN

900.81 INJURY TO EXTERNAL JUGULAR VEIN

900.82 INJURY TO MULTIPLE BLOOD VESSELS OF HEAD AND NECK

900.89 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF HEAD AND NECK

900.9 INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK

 

MRA of chest (procedure code 71555, C8909, C8910, C8911):

 

415.0 ACUTE COR PULMONALE

415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION

415.12 SEPTIC PULMONARY EMBOLISM

415.13 SADDLE EMBOLUS OF PULMONARY ARTERY

415.19 OTHER PULMONARY EMBOLISM AND INFARCTION

416.0 PRIMARY PULMONARY HYPERTENSION

416.2 CHRONIC PULMONARY EMBOLISM

416.8 OTHER CHRONIC PULMONARY HEART DISEASES

416.9 CHRONIC PULMONARY HEART DISEASE UNSPECIFIED

441.01 DISSECTION OF AORTA THORACIC

441.03 DISSECTION OF AORTA THORACOABDOMINAL

441.2 THORACIC ANEURYSM WITHOUT RUPTURE

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

786.00 RESPIRATORY ABNORMALITY UNSPECIFIED

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

 

MRA of peripheral arteries of lower extremities (procedure code 73725, C8912, C8913, C8914):

 

250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED

250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

440.29 OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES

440.30 ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES

440.31 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES

440.32 ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES

440.4 CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES

442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY

443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

443.81 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE

443.82 ERYTHROMELALGIA

443.89 OTHER PERIPHERAL VASCULAR DISEASE

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

 

MRA of abdomen (procedure code 74185, C8900, C8901, C8902):

 

151.0 MALIGNANT NEOPLASM OF CARDIA

151.1 MALIGNANT NEOPLASM OF PYLORUS

151.2 MALIGNANT NEOPLASM OF PYLORIC ANTRUM

151.3 MALIGNANT NEOPLASM OF FUNDUS OF STOMACH

151.4 MALIGNANT NEOPLASM OF BODY OF STOMACH

151.5 MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED

151.6 MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH

151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

152.0 MALIGNANT NEOPLASM OF DUODENUM

152.1 MALIGNANT NEOPLASM OF JEJUNUM

152.2 MALIGNANT NEOPLASM OF ILEUM

152.3 MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM

152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE

152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE

153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON

153.2 MALIGNANT NEOPLASM OF DESCENDING COLON

153.3 MALIGNANT NEOPLASM OF SIGMOID COLON

153.4 MALIGNANT NEOPLASM OF CECUM

153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS

153.6 MALIGNANT NEOPLASM OF ASCENDING COLON

153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

156.0 MALIGNANT NEOPLASM OF GALLBLADDER

156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS

156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER

156.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS

156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM

158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM

158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

159.0 MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED

159.1 MALIGNANT NEOPLASM OF SPLEEN NOT ELSEWHERE CLASSIFIED

159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS

159.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM

171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN

188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER

188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER

188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER

188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER

188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER

188.5 MALIGNANT NEOPLASM OF BLADDER NECK

188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE

188.7 MALIGNANT NEOPLASM OF URACHUS

188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER

188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED

189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS

189.1 MALIGNANT NEOPLASM OF RENAL PELVIS

189.2 MALIGNANT NEOPLASM OF URETER

189.3 MALIGNANT NEOPLASM OF URETHRA

189.4 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS

189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS

189.9 MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED

198.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY

223.0 BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS

223.1 BENIGN NEOPLASM OF RENAL PELVIS

233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS

236.90 NEOPLASM OF UNCERTAIN BEHAVIOR OF URINARY ORGAN UNSPECIFIED

236.91 NEOPLASM OF UNCERTAIN BEHAVIOR OF KIDNEY AND URETER

236.99 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS

401.0 MALIGNANT ESSENTIAL HYPERTENSION

401.1 BENIGN ESSENTIAL HYPERTENSION

401.9 UNSPECIFIED ESSENTIAL HYPERTENSION

402.00 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.10 BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.90 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

403.00 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

403.01 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

403.10 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

403.11 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

403.90 HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

403.91 HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.00 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.02 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.10 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.12 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.90 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

404.92 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

405.01 MALIGNANT RENOVASCULAR HYPERTENSION

405.11 BENIGN RENOVASCULAR HYPERTENSION

405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION

440.1 ATHEROSCLEROSIS OF RENAL ARTERY

441.02 DISSECTION OF AORTA ABDOMINAL

441.03 DISSECTION OF AORTA THORACOABDOMINAL

441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE

444.01 SADDLE EMBOLUS OF ABDOMINAL AORTA

444.09 OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA

447.1 STRICTURE OF ARTERY

447.3 HYPERPLASIA OF RENAL ARTERY

580.0 ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

580.4 ACUTE GLOMERULONEPHRITIS WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

580.81 ACUTE GLOMERULONEPHRITIS IN DISEASES CLASSIFIED ELSEWHERE

580.89 ACUTE GLOMERULONEPHRITIS WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY

580.9 ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.0 NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

581.1 NEPHROTIC SYNDROME WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

581.2 NEPHROTIC SYNDROME WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

581.3 NEPHROTIC SYNDROME WITH LESION OF MINIMAL CHANGE GLOMERULONEPHRITIS

581.81 NEPHROTIC SYNDROME IN DISEASES CLASSIFIED ELSEWHERE

581.89 OTHER NEPHROTIC SYNDROME WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.9 NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.0 CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

582.1 CHRONIC GLOMERULONEPHRITIS WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

582.2 CHRONIC GLOMERULONEPHRITIS WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

582.4 CHRONIC GLOMERULONEPHRITIS WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

582.81 CHRONIC GLOMERULONEPHRITIS IN DISEASES CLASSIFIED ELSEWHERE

582.89 OTHER CHRONIC GLOMERULONEPHRITIS WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.9 CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.0 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

583.1 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

583.2 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

583.4 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

583.6 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RENAL CORTICAL NECROSIS

583.7 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RENAL MEDULLARY NECROSIS

583.81 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC IN DISEASES CLASSIFIED ELSEWHERE

583.89 OTHER NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.9 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

588.0 RENAL OSTEODYSTROPHY

588.1 NEPHROGENIC DIABETES INSIPIDUS

588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)

588.89 OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION

588.9 UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION

593.81 VASCULAR DISORDERS OF KIDNEY

593.9 UNSPECIFIED DISORDER OF KIDNEY AND URETER

996.81 COMPLICATIONS OF TRANSPLANTED KIDNEY

V12.59 PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED

 

 

MRA of pelvis (procedure code 72198, C8918, C8919, C8920)

 

233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS

236.90 NEOPLASM OF UNCERTAIN BEHAVIOR OF URINARY ORGAN UNSPECIFIED

236.91 NEOPLASM OF UNCERTAIN BEHAVIOR OF KIDNEY AND URETER

236.99 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED URINARY ORGANS

442.2 ANEURYSM OF ILIAC ARTERY

443.22 DISSECTION OF ILIAC ARTERY

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

 

 

Documentation Requirements

 

• Documentation maintained in the patient’s file must indicate the medical necessity of this procedure.

o All coverage criteria listed in the “Indications and Limitations of Coverage and/ or Medical Necessity” section must be documented in the patient’s medical record, as well as a hard copy of the procedure results and made available to Medicare upon request.

o This information can generally be found in the office/progress notes, history and physical, and/or operative notes.

• If the provider of the magnetic resonance angiography study is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies.

o The physician must state the reason for the MRA in his order for the test.

• MRA and contrast angiography (CA) are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy.

o Only one of these tests will be covered routinely unless the physician can demonstrate the medical need to perform both tests.

o The medical record must clearly document the medical necessity of performing both tests.

• Examples of indications that support medical necessity of contrast angiography (CA) performed as an adjunct to MRA are given below:

o Clarify conditions where test results or clinical information are contradictory. (e.g., MRA and duplex Doppler ultrasound are discordant with the clinical differential diagnosis and conventional angiography, with its ability to directly measure pressure gradients across stenosis of questionable hemodynamic significance, can provide more definitive information).

o Verify the site of clinically important vascular stenosis and help map out the surgical/endovascular approach. (e.g., to determine which lesions should have an angioplasty and/or stent vs. which lesions require surgical bypass graft or no treatment at all).

o Identify situations where MRA is nonconclusive or degraded by metallic artifact.

Treatment Logic

• Magnetic Resonance Angiography (MRA) is an application of magnetic resonance (MR) imaging that provides visualization of blood flow, as well as images of normal and diseased blood vessels.

• Since MRA contrast agents are not nephrotoxic and are rarely associated with allergic type reactions, MRA without or with gadolinium-based contrast enhancement is an imaging alternative for patients who cannot tolerate iodine-based contrast media.

 

 

Sources of Information and Basis for Decision

 

American College of Radiology (2001). ACR Practice Guideline for the Performance of Pediatric and Adult Neurovascular Magnetic Resonance Angiography (MRA).

 

FCSO LCD 29218, Magnetic Resonance Angiography (MRA), 10/01/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Grainger & Allison’s. (2001). “Diagnostic Radiology: A Textbook of Medical Imaging”, (4th ed.) Churchill Livingstone Inc.

 

Koelemay, M. et al. (2001). “Magnetic Resonance Angiography for the Evaluation of Lower Extremity Arterial Disease”, JAMA. 2001; 285:1338-1345.

 

Leung, D.A., et al., “MR Angiography of the Renal Arteries”, Radiology Clinics of North America, 40(4): 847-65, 2002.

 

NIA Diagnostic Imaging Guidelines. [on-line]. Available: http://www.radmd.com/assets/20050305_guidelines.pdf [2005, March]

 

 

AMA CPT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD MAGNETIC RESONANCE ANGIOGRAPHY (MRA)